430752951-10-25-2019-07-CC-SCES-BHASFE-20191025135012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430752951
Report Date: 10/25/2019
Date Signed: 10/25/2019 01:50:25 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:	GOULARTE, PATTY		FACILITY NUMBER:	430752951
ADMINISTRATOR:	GOULARTE, PATTY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 683-2738
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY:	12	CENSUS: 11	DATE:	10/25/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Patty Goularte		TIME COMPLETED:	11:30 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	LPA and LPM Susy Cervantes and Mary Segura met with licensee Patty Goularte for an annual/random inspection and explained the nature of today’s visit. Present were Licensee, her husband Paul and her adult son Harry with eleven children of which three are infants. Assistant Elena arrived shortly after. Adults living in the home are Licensee, her husband, and adult son. 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 10/24/19 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. 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 no wall heaters. LPA observed barricaded stairs. Off limits indoor: two bathrooms, living room, entire upstairs. There are two bodies of water: the pool is properly fenced, the fishpond had the left corner of the wire fence that was not attached. Licensee stated there are no firearms/weapons in the home. LPA observed a 4A60BC fire extinguisher that was last serviced on 11/7/2018. Smoke detector and Carbon Monoxide detectors are operable. 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. Medicines, poisons and cleaning supplies are inaccessible to the children and stored in pantry inside the house and locked in cabinets. Continues on report dated 10/25/2019

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019

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 3

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: GOULARTE, PATTY	FACILITY NUMBER: 430752951
	VISIT DATE: 10/25/2019

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

Continuation of report dated 10/25/2019
Backyard is fenced. There are 5 cats, Licensee stated cats are vaccinated. Off limits outdoor: far back yard where son lives, it is fenced off, and pool that is fenced as well.

LPA reminded licensee that she can only have 14 children according to her license. Children were supervised during the visit and LPA went over substitute options. Licensee stated that she does transport children, LPA reminded Licensee that children are never to be left in parked vehicles.

LPA did not observe a completed roster of the children. A fire and disaster drill log that was last conducted on 6/13/2019. LPA reviewed five children’s files. Children’s immunization records are documented, maintained, and updated in form PM286. LPA observed Notification of Parents’ Rights is in each child’s file. LPA observed that the Licensee and assistant have completed Mandated Reporter training on 5/3/2018 and 4/29/2018. Licensee and Assistant have Pediatric CPR/1^st Aid expiring 5/2021 and 3/30/2021. Licensee and assistant have all needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza (decline statement observed) as well as TB testing in file.
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.
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 B deficiencies were cited during today's inspection.
Notice of site visit must remain posted for 30 days

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: GOULARTE, PATTY	FACILITY NUMBER: 430752951
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/25/2019 Section Cited	1 2 3 4 5 6 7	Operation of a Family Child Care Home All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.
	8 9 10 11 12 13 14	This reqirement was not met as evidence by: the fishpond had the left corner of the wire fence that was not attached to the stair railing. This poses a potential risk to the health and safety of the children in care.	8 9 10 11 12 13 14
Type B 10/25/2019 Section Cited	1 2 3 4 5 6 7	Operation of a Family Child Care Home Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Licensee was unable to provide a completed roster. This poses a potential risk to the health and safety of the childrne in care.	8 9 10 11 12 13 14

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: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3