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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423437
Report Date: 10/01/2026
Date Signed: 10/01/2026 03:41:27 PM

Document Has Been Signed on 10/01/2026 03:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:BROOM-JACKSON, LORI & BROOM, GERALDEANFACILITY NUMBER:
013423437
ADMINISTRATOR/
DIRECTOR:		BROOM-JACKSON, LORIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 501-8776
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY: 14TOTAL ENROLLED CHILDREN: 3CENSUS: 3DATE:
10/01/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Lori Broom-JacksonTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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On 10/01/2026 at 2:05pm, Licensing Program Analyst (LPA) Jialing “Julianne” Zhu met with licensee Lori Broom-Jackson for an unannounced annual inspection. Upon arrival, LPA provided licensee a copy of the Entrance Checklist (LIC 126). The facility is a two-story home. Also residing in the home is Co-Licensee Geraldean “Gerry” Broom. The home was toured to conduct a Health and Safety Inspection in the on-limits areas only. The facility’s current hours of operation are Monday - Friday from 7:30am - 4:00pm.

Ratio/Capacity: The facility operates as a large Family Child Care Home licensed with a capacity of 14 children. At the time of the inspection, there were three (3) children (1 infant and 2 preschool-aged) in care. The facility is within ratio and in compliance with capacity regulations today.

On-limit Areas (accessible by children in care): The on-limit areas are on the first floor only: dining room (main daycare area), family room (main daycare area), kitchen, half bathroom, and a portion of the backyard. The isolation area for sick children is dining room. The inside of the home is observed to be clean and orderly, with central heating, cooling, and ventilation for safety and comfort. LPA observed there are ample safe and age-appropriate toys, play equipment and materials. All toxins, cleaning products, and hazardous materials have been made inaccessible to children. There is an electric fireplace in the family room. Stairs in the home are fenced and barricaded with a moveable gate.

The outdoor play area is a portion of the backyard, which is completely fenced with visual supervision. The outdoor play area is free from defects or dangerous conditions. There is an ample supply of age-appropriate toys and activities available for children, and they are in good condition. There is ample shade available, and gates are locked at all times while children are in the backyard. Licensees may also take children to the neighborhood park. There are no pools, hot tubs, or similar bodies of water on premises.

Page 1 of 3. See LIC 809C.

Chandra Charles
Jialing Zhu
DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2026
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: BROOM-JACKSON, LORI & BROOM, GERALDEAN
FACILITY NUMBER: 013423437
VISIT DATE: 10/01/2026
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Off-limit Areas (not accessible by children in care): The off-limit areas on the first floor are the bedroom, garage, side portion of backyard. The entire second floor (bedrooms & bathrooms) are off-limits to children. All off-limit areas are inaccessible by closed and/or locked doors and visual supervision. LPA advised licensee she must contact Licensing for an inspection prior to changing an OFF-Limit area to ON-Limit.

Child Care Operations: Licensee provides meals and snacks for children. LPA observed three (3) play yards in the facility with the correct size mattresses and fitted sheets. Bedding is provided by parents when needed. Licensee was reminded that all food and bedding brought from children’s home are to be labeled with the children’s name and stored appropriately. Licensee currently does not provide transportation to children in care.

Emergency Preparedness/Safety: A fully charged 3A40BC fire extinguisher is located in the kitchen. LPA observed at one functional smoke detector and one carbon monoxide detector in the family room. Fire/disaster drills are conducted at least once every six months, and the last drill was on 09/16/2026. The home is equipped with telephone service and first aid supplies. Per licensee, there are no firearms and no pets in the home. Licensee confirmed that there are no Registered Sex Offenders living in the facility.

Recordkeeping Review: All adults living in the home have obtained a criminal record clearance. Licensee’s Pediatric CPR/First Aid certification is current and expires on 07/15/2027. Licensee’s Mandated Reporter training for Child Care Providers is current and expires on 12/12/2026. The licensee is in compliance with the immunization laws.

A current facility roster is available for review. LPA reviewed three (3) children’s files. Files are complete. 15-minute sleep checks were conducted and documented for all infants ages 0-24 months. The licensee rents the property. Landlord notification of child care operations are on file. The facility has liability insurance. All required Licensing documents are posted by the main entrance.

Licensee was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Incidents must be reported within 24 hours by phone, fax, or email. LPA informed the Licensee that all forms can be downloaded at www.ccld.ca.gov.

Licensee was also reminded that Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting https://mandatedreporterca.com/. Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years.

Page 2 of 3. See LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Jialing Zhu
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: BROOM-JACKSON, LORI & BROOM, GERALDEAN
FACILITY NUMBER: 013423437
VISIT DATE: 10/01/2026
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Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep, as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

No deficiencies cited during today's inspection. A Notice of Site Visit was given and must remain posted for 30 days. Exit interview was conducted, report was reviewed, and Appeal Rights were provided to licensees Lori Broom-Jackson.

Page 3 of 3. End of Report.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Jialing Zhu
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4