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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274401929
Report Date: 02/13/2020
Date Signed: 02/13/2020 12:40:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:STAMBACK, PATRICIAFACILITY NUMBER:
274401929
ADMINISTRATOR:STAMBACK, PATRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 385-4748
CITY:KING CITYSTATE: CAZIP CODE:
93930
CAPACITY:14CENSUS: 9DATE:
02/13/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Patricia StambackTIME COMPLETED:
12:45 PM
NARRATIVE
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On 02/13/20 at 10:00 am, Licensing Program Analyst (LPA) Susy Cervantes met with licensee Patricia Stamback for an annual/random inspection and explained the nature of today’s visit. Present were Licensee with nine children: three infants and six preschool age. Licensee stated her assistant had just left to a doctor's appointment and did not know at what time she would be back. Adults living in the home are Licensee and her son Jeffrey. Days and hours of operation are Monday through Friday, 7:00 am to 6:00 pm.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 02/10/20 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100 per person per day, minimum of $100 to a maximum of $500 per person for an initial violation, and a minimum of $100 to a maximum of $3000 per person for any subsequent violation within a 12-month period. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevent them from returning to the home or having contact with children in care.

LPA toured the inside and outside of the home. LPA observed a covered fireplace and no wall heaters. LPA observed no stairs. Off limits indoor: attached garage and master bathroom. There are no bodies of water. Licensee stated there are no firearms/weapons in the home. LPA observed a 3A40BC fire extinguisher that was last serviced on 11/13/19. Smoke detector and Carbon Monoxide detectors are operable.

Continues on report dated 02/13/2020
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2020
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: STAMBACK, PATRICIA
FACILITY NUMBER: 274401929
VISIT DATE: 02/13/2020
NARRATIVE
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Continuation of report dated 02/13/2020

LPA observed sufficient materials, toys, and play equipment for the children in care as well as safe healthful, and comfortable accommodations, furnishings, and equipment. Telephone is in working order. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Backyard is fenced. There is a dog and Licensee stated it is vaccinated. Off limits outdoor: two locked sheds.

At 10:20 am, Licensee made a phone call, at 10:28 am a parent came to the facility and picked up two children. LPA reminded licensee that she can only have 14 children according to her license with a qualified assistant, when she is alone her capacity changes to a small license. Children were supervised during the visit and LPA went over substitute options. Licensee stated that she does not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.

LPA took a picture of a roster of the children, however the roster is incomplete. LPA observed a fire and disaster drill log that was last conducted on 12/21/19. LPA reviewed 12 children’s files. Children’s immunization records are not documented, maintained, and updated in form PM286 for Child 5, 7, 9, and 10. LPA observed Notification of Parents’ Rights is in each child’s file. LPA observed that the Licensee has not completed Mandated Reporter training and advised licensee to take online course at www.mandatedreporterca.com, this is a repeat violation from report dated 03/25/19, however violation was not cleared. Licensee has Pediatric CPR/1st Aid expiring 4/21. Licensee and assistants have all needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

Continues on report dated 02/13/2020
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2020
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: STAMBACK, PATRICIA
FACILITY NUMBER: 274401929
VISIT DATE: 02/13/2020
NARRATIVE
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Continuation of report dated 02/13/2020

Licensee was reminded that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice. LPA discussed the immediate civil penalties for Zero Tolerance of $500 and AB633 requirements for type A violation. Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility. Safe sleep was discussed with the Licensee and Guide to Safe Sleep information was provided to the licensee. Department website: http://ccld.ca.gov provided to Licensee.

Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. An exit interview was conducted with Licensee. LPA reviewed deficiencies, plans of correction, and licensee was given appeal rights. Type A and B deficiencies were cited during today’s inspection. Notice of site visit must remain posted with cited deficiency Type A for 30 days
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2020
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: STAMBACK, PATRICIA
FACILITY NUMBER: 274401929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2020
Section Cited

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102416.5(b)(2) Staffing Ratio and Capacity: For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time... Six children, no more than three of whom may be infants.
This requirement was not met as evidence by:
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Based on observation, interview, and record review, the licensee did not maintain her capacity and ratio for a small license, since licensee was alone. This presents an immediate risk to the health and safety of the children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2020
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: STAMBACK, PATRICIA
FACILITY NUMBER: 274401929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2020
Section Cited

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102418(g)(1) Immunizations: The licensee shall document each child's immunizations... and shall maintain such documentation for as long as the child is enrolled.This requirement includes updating each child's PM 286...
This requirement was not met as evidence by:
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Based on record review, the licensee did not keep child 5, 7, 9, and 10 immunizations documented on form PM 286. This poses a potential risk to the health and safety of the children in care.
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Type B
02/28/2020
Section Cited

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102417(g)(8)(A) Operation of a Family Child Care Home
Each family child care home shall have a current roster of children... The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This requirement was not met as evidence by:
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Based on observations and record review licensee did not maintain a current roster with all required information. This poses a potential risk to the health and safety of the children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2020
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: STAMBACK, PATRICIA
FACILITY NUMBER: 274401929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2020
Section Cited

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1596.8662: Effective January 1, 2018 all staff of Child Care Centers and Family Child Care Homes are required to complete the Mandated Reporter Training. New staff have 90 day to complete the training. The training must be renewed every 2 years. This requirement was not met as evidence by:
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Based on interview and record review, licensee did not complete Mandated reporter training. This is a repeat violation within 12 months. This poses a potential risk to the health and safety of the children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2020
LIC809 (FAS) - (06/04)
Page: 6 of 6