<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 034500295
Report Date: 09/21/2023
Date Signed: 09/21/2023 10:42:25 AM

Document Has Been Signed on 09/21/2023 10:42 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BLUM, CHRISTINA & JOSHUAFACILITY NUMBER:
034500295
ADMINISTRATOR:CHRISTINA & JOSHUA BLUMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 588-3455
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
09/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Joshua & Christina BlumTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/21/2023, Licensing Program Analyst Katy Velazquez (LPA) conducted an unannounced field visit for the purpose of a case management inspection. LPA arrived at the Family Child Care Home (FCCH) and was met by Licensee Joshua Blum (L1), and Licensee Christina Blum (L2) arrived shortly after LPA's arrival. LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. LPA toured the facility and observed 5 preschool aged children being supervised by L1. Also present in the FCCH was L1's adult brother. LPA determined, through accessing Guardian, that all required adults were background cleared and associated to the license.

Based on interviews, a 3-year-old child was placed in a play yard for nap time. The child is physically able to climb out of the play yard. This poses a potential risk to the health and safety of children in care. As a result, a Type-B deficiency was cited on a subsequent 809-D page.

An exit interview was conducted, and the report was reviewed with L1 and L2. LPA provided L1 and L2 with Licensee Appeal Rights. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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 2
Document Has Been Signed on 09/21/2023 10:42 AM - It Cannot Be Edited


Created By: Katy Velazquez On 09/21/2023 at 10:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLUM, CHRISTINA & JOSHUA
FACILITY NUMBER: 034500295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
102425

1
2
3
4
5
6
7
INFANT SAFE SLEEP (a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. This requirement was not met as evidenced by interview statements that children over age 2 years nap in play yards and LPA observation on 08/29/2023.
1
2
3
4
5
6
7
L1 and L2 will review the Safe Sleep documents provided by LPA. L1 and L2 will email LPA a signed statement, by 09/28/2023, aknowledging that they understand and will adhere to Safe Sleep
8
9
10
11
12
13
14
8
9
10
11
12
13
14
Regulations including the use of play yards and having infants sleep on the main floor of the home with adult supervision.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Karyn Guerra
LICENSING EVALUATOR NAME:Katy Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2