354415286-3-11-2025-07-CC-PSGZ-DENNSA-20250311104248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 354415286
Report Date: 03/11/2025
Date Signed: 03/11/2025 10:43:06 AM

Document Has Been Signed on 03/11/2025 10:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	ROBISON, ITSARIYABHORN		FACILITY NUMBER:	354415286
ADMINISTRATOR/ DIRECTOR:	ROBISON, ITSARIYABHORN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 524-2288
CITY:	HOLLISTER	STATE: CA	ZIP CODE:	95023
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 13	CENSUS: 12	DATE:	03/11/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:11 AM
MET WITH:	Itsariyabhorn Robison		TIME VISIT/ INSPECTION COMPLETED:	10:55 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Pedro Solorio met with licensee Itsariyabhorn Robison for a required one year visit. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's mother, and 12 day care children including three infants. Days and hours of operation are Monday to Friday, 7:30am to 5:00pm. The adults that reside in the home are licensee, her husband, and two minor children. A review of staff records on 03/10/2025 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 Itsariyabhorn Robison was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption prior to initial presence in a Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if the regulation is violated. 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. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged and serviced 3A40BC fire extinguisher and a working smoke and carbon monoxide detector. Licensee states there are no weapons/ firearms in the home. Off limit areas indoor: three bedrooms, one bathroom, kitchen, dining area and laundry area. There are no bodies of water. Backyard is fenced. Off limits outdoor: right side and back right side of home that is fenced off to children including large storage. Licensee stated there are no animals at the facility. LPA observed licensee has a current CPR and First Aid certification expiring 05/27/2025. Licensee completed Mandated Reporter training on 10/23/2024. Licensee’s mother has a current CPR and First Aid certification expiring 5/27/2025. Licensee’s mother completed Mandated Reporter training on 6/4/2023.

Susy Cervantes	TELEPHONE: (408) 324-2152
Pedro Solorio-Gutierrez	TELEPHONE: (916) 956-5037
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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

Document Has Been Signed on 03/11/2025 10:43 AM - It Cannot Be Edited

Created By: Pedro Solorio-Gutierrez On 03/11/2025 at 10:24 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ROBISON, ITSARIYABHORN	FACILITY NUMBER: 354415286
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above: C1, C2, C3, C4, C8 are missing MMR vaccine update in files, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/01/2025
	Plan of Correction
1 2 3 4	Licensee will provide updated MMR vaccination proof for all children that were missing the proof in thier files. Licensee will submit the proof by Plan of Correction Date: April 1, 2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Susy Cervantes

TELEPHONE: (408) 324-2152

LICENSING EVALUATOR NAME:

Pedro Solorio-Gutierrez

TELEPHONE: (916) 956-5037

LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ROBISON, ITSARIYABHORN	FACILITY NUMBER: 354415286
	VISIT DATE: 03/11/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed a current roster of the children and a fire and disaster drill log which was last completed on 11/04/2024. LPA reviewed 10 children's files -- C1, C2, C3, C4, C8 are missing MMR vaccine update in file. LPA observed sleep logs and LIC 9227s for all infants Licensee states day care is not insured. LPA discussed SB792 Immunization Requirements and observed licensee has immunization records on file. No IMS is administered by the facility.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

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 eight 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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding www.cdss.cs.gov/inforesources/community-care-licensing/inspection-process.

LPA discussed the safe sleep regulations with Licensee Itsariyabhorn Robison and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee Itsariyabhorn Robison 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.

SUPERVISOR'S NAME: Susy Cervantes	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Pedro Solorio-Gutierrez	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ROBISON, ITSARIYABHORN	FACILITY NUMBER: 354415286
	VISIT DATE: 03/11/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensee Itsariyabhorn Robison was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE ITSARIYABHORN ROBISON confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the licensee Itsariyabhorn Robison.

The following type B deficiencie(s) 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.

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: Susy Cervantes	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Pedro Solorio-Gutierrez	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4