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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214200082
Report Date: 06/11/2019
Date Signed: 06/11/2019 03:18:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GOCHBERG, CLAIRE & JODIFACILITY NUMBER:
214200082
ADMINISTRATOR:GOCHBERG, CLAIRE & JODIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 459-5624
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:14CENSUS: 10DATE:
06/11/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Licensee, Jodi GochbergTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA), Luis J. Gomez met with Licensees, Jodi Gochberg and Claire Gochberg. Purpose of the inspection was explained and was for an Annual/Random inspection. Present in the facility is both licensees and helper caring for 10 children ( 4 Infants 6 PreK). Licensee is within capacity limits of the License. Licensee’s home is a 3 bedroom 2 bathroom, 1- level house. Hours of Operation are: Mon- Fri 7:00- 5:45pm Daycare areas are: Living Room, Play Room, Bedroom #1, Bedroom #2, Bathroom #1, Kitchen and Yard Area. Off Limit areas are: Bathroom #2. LPA observed the following: Daycare area is clean, orderly, and equipped with age appropriate toys and equipment for the children. LPA inspected the yard area for health and safety hazards. LPA observed all toys and equipment are in good working condition. Home has ample lighting and ventilation throughout. Home has a telephone and a working smoke detector located in the hallway. Home has a working carbon monoxide detector, and a fully charged fire extinguisher located in the kitchen.

There are no poisons, detergents, cleaning products, or sharp objects accessible to daycare children. Licensee states there are no guns or weapons in the home. Licensee’s cardiopulmonary resuscitation certifications expires: 02/2021. Licensee conducted last emergency drill on 6/7/2019 and is properly logged. Licensee states she provides daily snacks for children in care. All required postings are properly posted in the day care. Licensee states there are no pets in the home.

LPA reviewed children’s files and the facility roster during today’s inspection. LPA observed children’s files and the facility roster are complete and up to date.

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SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GOCHBERG, CLAIRE & JODI
FACILITY NUMBER: 214200082
VISIT DATE: 06/11/2019
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During inspection,
*Incidental Medical Services (IMS) policy was discussed.
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*Licensee was given information regarding ‘Safe Sleep’ practices.

>No deficiencies were issued today under Title 22 Division 12 of the Ca. Code of Regulations.

>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
LIC809 (FAS) - (06/04)
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