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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274401929
Report Date: 03/30/2022
Date Signed: 03/30/2022 12:13:53 PM


Document Has Been Signed on 03/30/2022 12:13 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
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: 3DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Patricia StambackTIME COMPLETED:
12:30 PM
NARRATIVE
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On 03/30/2022 at 09:35 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Patricia Stamback, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee their daughter that was visiting with 3 children: two preschool and one infant. Adults living in the home are licensee. Days and hours of operation are Monday through Friday 7:00 AM to 5:30 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 03/29/2022 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. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA inspected inside and outside of the home. LPA observed a covered fire place, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated they have a dog and they are vaccinated. LPA observed a 3A40BC fire extinguisher that was serviced on 04/20/21. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored in the top kitchen cabinet and top of the refrigerator. Backyard is fenced. Off limit areas: three bedrooms, one bathroom, garage, two sheds.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to their license with an assistant. Licensee stated they do 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.


Continues on report dated 03/30/2022 pg. 1/2
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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Document Has Been Signed on 03/30/2022 12:13 PM - It Cannot Be Edited

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: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which the last drill long was conducted on 07/05/2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee will conduct a disaster drill and will document and submit the drill to the San Jose Regional Office (SJRO) by close of business (cob) on April 13, 2022.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which licensee has not renewed the Mandated Reporter which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Licensee will complete and submit Mandated reporter training certificate of completion to SJRO by cob April 29, 2022.

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: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2022 12:13 PM - It Cannot Be Edited

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: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which licensee's CPR and First aid has expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Licensee will submit proof of enrollment to a CPR and First aid class, once completed they will submit proof of completion to the SJRO by cob April 29, 2022.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which Child 05's immunizations have not been documented on PM 286 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee will complete PM 286 and submit a copy of the completed form to SJRO by cob on April 13, 2022

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: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2022 12:13 PM - It Cannot Be Edited

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: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which Child 05's parents did not sign LIC 995A which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee will provide LIC 995A to Child 05's parents and will submit a copy of the completed form to SJRO by cob on April 13, 2022
Section Cited
Child's Records
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2022 12:13 PM - It Cannot Be Edited

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: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which LIC 9227 was missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee will provide LIC 9227 to Child 05's parents and will submit a copy of the completed form to SJRO by cob on April 13, 2022.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 15 minute check log has not been created which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee will create and document in a sleep log 15 minute checks for infants under 24 months. Licensee will submit copies of completed logs to SJRO by cob April 13, 2022

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: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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
VISIT DATE: 03/30/2022
NARRATIVE
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Continuation of report dated 03/30/2022 pg. 2/2

LPA took a picture of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 07/05/21. LPA reviewed 5 children’s files and observed Child 05 had missing signatures on LIC 995 and 9150, CDPH 286 is not complete. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was provided and discussed and a 15 minute check sleep log for infants under 24 months was discussed. LPA observed that the Licensee has expired Mandated Reporter training, training was completed on 02/26/20. Licensee has expired Pediatric CPR/1st Aid expired 04/20/21. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee.

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 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.

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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Type B deficiencies were cited during today's visit. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.


Exit interview conducted and report was reviewed with the licensee, Patricia Stamback. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC809 (FAS) - (06/04)
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