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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354415286
Report Date: 07/15/2021
Date Signed: 07/15/2021 12:39:38 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:ROBISON, ITSARIYABHORNFACILITY NUMBER:
354415286
ADMINISTRATOR:ROBISON, ITSARIYABHORNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 524-2288
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:14CENSUS: 7DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Itsariyabhorn RobisonTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Itsariyabhorn Robison for a required 1 year visit. LPA explained the nature of today’s inspection to her. Present were licensee and seven children including licensee's 5 and 4 year old son. Days and hours of operation are Monday to Friday, 7:00am to 5:00pm. The adults that reside in the home are licensee and her husband.

A review of staff records on 06/28/2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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 prevents them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed a barricaded fireplace in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed medication and knives accessible to children in a kitchen drawer. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a working smoke detector and a working carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: Master bedroom/bath, two bedrooms and bathroom. There are no bodies of water. Backyard is fenced. Off limits outdoor: fenced off areas on the right side of the home. Both areas were unlocked and accessible to children. LPA observed yard tools in the back area and a blow torch and yard tools in the area to the right of the home accessible to children. LPA observed one pet dog in the home. LPA observed licensee has a current CPR and First Aid certification expiring 09/01/2021 and completed Mandated Reporter training on 09/2019.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
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
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: ROBISON, ITSARIYABHORN
FACILITY NUMBER: 354415286
VISIT DATE: 07/15/2021
NARRATIVE
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LPA observed a current roster of the children and a fire and disaster drill log which was last completed on 07/05/2021. LPA reviewed five children's files and observed all forms are completed. Child 1, 2, 4 and 5 do not have current immunization records on file. Licensee states day care is not insured. LPA observed LIC282 in children's files. LPA discussed SB792 Immunization Requirements and observed licensee has current immunizations on file.

Supervision of children was discussed with licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

Safe sleep update: LPA discussed the new “Safe Sleep” regulations with the Licensee including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee. LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, and all infants shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPA discussed Zero Tolerance with $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee and provided her the AB633 fact sheet and licensee understands the requirements. Incidental Medical Services were discussed with the licensee. 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.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: ROBISON, ITSARIYABHORN
FACILITY NUMBER: 354415286
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited

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Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
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This requirement was not met as evidenced by LPA observed medication and knives accessible to children in a kitchen drawer and yard tools in the back area and a blow torch and yard tools in the area to the right of the home accessible to children. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.

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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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ROBISON, ITSARIYABHORN
FACILITY NUMBER: 354415286
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2021
Section Cited

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Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. This requirement was not met as evidenced by Child 1, 2, 4 and 5 do not have current immunization records on file.
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This poses a potential risk Health, Safety Personal Rights risk to 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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4