Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243909084
Report Date: 08/10/2017
Date Signed 08/11/2017 09:35:42 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:JARAMILLO, JACQUELINE FAMILY CHILD CAREFACILITY NUMBER:
243909084
ADMINISTRATOR:JARAMILLO, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 725-9452
CITY:MERCEDSTATE: CAZIP CODE:
95341
CAPACITY:14CENSUS: 9DATE:
08/10/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Licensee, Jacqueline JaramilloTIME COMPLETED:
11:30 AM
NARRATIVE
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(3) An unannounced Annual/Random inspection was conducted today by Licensing Program Analyst, Frances Ortiz. Present during the inspection was licensee, assistant and 9 day-care children. Background clearances were discussed and licensee signed LIS531 indicating all adults residing and/or providing care and supervision have a criminal record clearance or exemption. Discussed SIDS with licensee and provided them with a copy of Child Care Provider's Guide to Safe Sleep.

NOT PROVIDING IMS SERVICES:
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

· The licensee has current pediatric CPR and First Aid that expire on 1/31/19.


· The home is clean and orderly, with heating and ventilation for safety and comfort.
· Safe, healthful, and comfortable accommodations, furnishings, and equipment were observed. Also observed toys, play equipment, and materials.
· A current roster of children in care is maintained. Verified that immunization records are maintained for children in care.
· The licensee ensures that children in care are supervised at all times.
· Capacity as specified on the license is being maintained.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Frances OrtizTELEPHONE: (559) 341-5431
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: JARAMILLO, JACQUELINE FAMILY CHILD CARE
FACILITY NUMBER: 243909084
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2017
Section Cited
102419(d)(1)
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Admission Procedures and Parental and Authorized Representative's Rights. (1 The license shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A. During visit LPA observed that child #3, #4 and #5 do not have signed Parents Rights Forms in their files. Also missing was signed Medical Consent Form.
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Licensee will obtain required licensing forms with authorized representative's signature. Licensee to submit Notice of Correction by 08/21/2017 confirming that the children's files are now complete. LPA will make return visit to verify Parents Rights and Consent for Medical Treatment forms are signed by authorized representative.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Frances OrtizTELEPHONE: (559) 341-5431
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2017
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: JARAMILLO, JACQUELINE FAMILY CHILD CARE
FACILITY NUMBER: 243909084
VISIT DATE: 08/10/2017
NARRATIVE
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·Fire and disaster drills are conducted at least once every six months, and documented with the date and time.
· Licensee states there are no firearms or ammunition are in the home.
· Detergents, cleaning compounds, medications and other items which could pose a danger to children are stored where they are inaccessible to children. Poisons are kept in a locked garage. · ·There is no fireplace in the home.
· Facility has required fire extinguishers and smoke detectors that meet State Fire Marshall standards. Facility has one or more functioning carbon monoxide detectors that meet the statutory requirements.
· No bodies of water were observed in or on the premises.

Hours of operation are Monday through Friday from 5:30 AM to 6:00 PM and as arranged; less than 24 hours. Licensee is reminded of inspection authority by employees of the Department at any time, with or without advance notice. Licensee understands children may not be left in parked vehicles. When temporarily absent from the home, the licensee arranges for a substitute adult to care for and supervise children in her absence.

In exit interview licensee is advised to post the Notice of Site Visit for 30 days and retain evaluation report for 3 years.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, the following deficiencies are found: (see LIC809-D)
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Frances OrtizTELEPHONE: (559) 341-5431
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2017
LIC809 (FAS) - (06/04)
Page: 3 of 3