354415286-2-17-2023-07-CC-DVIA-CP5SWE-20230217131414

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 354415286
Report Date: 02/17/2023
Date Signed: 02/17/2023 01:14:19 PM

Document Has Been Signed on 02/17/2023 01:14 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:	ROBISON, ITSARIYABHORN		FACILITY NUMBER:	354415286
ADMINISTRATOR:	ROBISON, ITSARIYABHORN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 524-2288
CITY:	HOLLISTER	STATE: CA	ZIP CODE:	95023
CAPACITY:	14	CENSUS: 10	DATE:	02/17/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Itsariyabhorn Robison		TIME COMPLETED:	01:25 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Deanna Villagrana and Teodoro Trujillo met with licensee Itsariyabhorn Robison for a case management visit and to deliver amended report for case management visit on 02/14/2023. Present were licensee, licensee assistant Yaritza Diaz Carrillo, her four year old son and nine day care children.

During the visit, LPAs observed a fenced off area in the backyard with a combo wood and 35 inch tall metal fence gate that would not stay secured making a lawn mower and several yard items accessible to children. Licensee tried latching gate but it would not stay secured since the fence it latches to is loose and not able to be secured properly. Licensee tied a rope to secure the gate to the fence making items inaccessible.

The following type A deficiency was cited on the attached page (809-D). Licensee was informed that failure to correct the deficiency 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.

LPAs Deanna Villagrana and Teodoro Trujillo informed licensee Itsariyabhorn Robison that this report dated 02/17/2023 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPAs Deanna Villagrana and Teodoro Trujillo informed the licensee Itsariyabhorn Robison to provide a copy of this licensing report dated 02/17/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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 Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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 02/17/2023 01:14 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: ROBISON, ITSARIYABHORN	FACILITY NUMBER: 354415286
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/18/2023 Section Cited	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	Licensee will submit photos of a secured fence and gate or remove items and making inaccessible to children to CCLD by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by LPAs observed a fenced off area in the backyard with a combo wood and 35 inch tall metal fence gate that would not stay secured making a lawn mower and several yard items accessible to children. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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