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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430752951
Report Date: 01/11/2022
Date Signed: 02/25/2022 07:54:00 AM


Document Has Been Signed on 02/25/2022 07:54 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:GOULARTE, PATTYFACILITY NUMBER:
430752951
ADMINISTRATOR:GOULARTE, PATTYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 683-2738
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:12CENSUS: 12DATE:
01/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Patty GoularteTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs), Susy Cervantes and Cortney Nelson, met with Licensee, Patty Goularte, for an unannounced Required- 1 Year Inspection. LPAs were granted access to the home by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were 12 children (3 infants, 9 preschool-age), the Licensee, and 1 assistant present, which is compliant with the home license capacity and ratio requirements. LPAs observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday, 7:00AM-5:30PM. (except currently on Wednesday and Friday home closes at 3:30PM)

Licensee states that adults over the age of 18, residing in the home are: herself, her spouse (Paul Bender), and her son (Harry Goularte). All adults residing in the home have Criminal Background Check Clearance, signed Criminal Record Statements (LIC508), and TB Test.

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 reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The last fire/disaster drill was conducted on 11/7/2021, which is compliant with the six-month requirement for homes. LPA observed a fully charged 4A60BC fire extinguisher (serviced 11/3/2021), functioning smoke detector and carbon monoxide detector. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. The Licensee states that there are no weapons or firearms in the home.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2022
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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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: 01/11/2022
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Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Patty Goularte.

As a result of todays inspection, no deficiencies were cited.

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.

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.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
LIC809 (FAS) - (06/04)
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