434402285-3-5-2020-07-CC-SYIP-BMESGA-20200305125137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434402285
Report Date: 03/05/2020
Date Signed: 03/05/2020 12:51:43 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:	LINDSETH, THERESA		FACILITY NUMBER:	434402285
ADMINISTRATOR:	LINDSETH, THERESA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 848-5051
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	14	CENSUS: 0	DATE:	03/05/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:33 AM
MET WITH:	Theresa Lindseth		TIME COMPLETED:	01:00 PM

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) Samantha Yip conducted an unannounced Required 1 Year inspection. LPA met with Licensee Theresa Lindseth and explained the reason for the inspection. Present during the inspection were Licensee and her spouse. There were no day care children present during today's inspection. The hours of operation are Tuesday through Friday 8:30AM to 11:30AM and Monday through Thursday 9AM to 12PM in the summer. License, Emergency Disaster Plan, and Notification of Parent's Rights were posted. There is working phone in the home. LPA toured the inside and outside of the home with Licensee. The off-limit areas of the home are the master bedroom, bedroom 2, 3, 4, laundry room, garage, screen room, left side of the backyard, and right side of the backyard. Licensee has a waiver for her fireplace to not be barricaded. All disinfectant, cleaning supplies, and other items that are dangerous to children were observed to be inaccessible. Furniture and equipment, such as tables and chairs, were observed to be age appropriate. LPA reminded Licensee to check any cracks in the furniture, such as chairs. LPA observed that there is sufficient amount of toys for children in care. Restroom for children was observed to be clean. LPA observed a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 01/11/2020. Licensee stated that there are no weapons, such as firearms, stored in the home. The backyard is used and is fenced. There is a play structure in the backyard, which is anchored to the ground. All play equipment were observed to be in good condition. There is ---------------------continues on 809 dated 03/05/2020 page 2--------------------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020

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: LINDSETH, THERESA	FACILITY NUMBER: 434402285
	VISIT DATE: 03/05/2020

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a pool and hot tub in the backyard. The pool does have a cover, which can bear the weight of an adult. The hot tub was locked. There were no other bodies of water observed during today's inspection.

Licensee stated that she does transport children when they go to the library. LPA provided Licensee with the updated Car Seat Law. Licensee also understands that children cannot be left alone and unattended in parked vehicles. Licensee also stated that she currently does not have any children in care who requires Incidental Medical Services.

A copy of the facility roster was obtain. 2 children's files were reviewed during today's inspection. The records reviewed include but not limited to parent's rights and immunization records.

Licensee does have a valid CRR/1st Aid, which expires on 12/30/2020. Licensee completed the General Mandated Reporter Training on 02/19/2020. LPA discussed with Licensee about taking the Child Care Provider Training and reminded Licensee that the Mandated Reporter Training requires renewal every two years. Licensee stated that she submit a copy of the certificate to Licensing. Licensee's immunization records for pertussis and measles on file.

The adults living in the home are Licensee, her spouse, and her two adults sons. All adults have cleared criminal record, child abuse index, and TB test. 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. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

LPA provided Licensee with Lead Exposure. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online Licensing Forms, Adoption of new Laws, etc.

As a result of today's inspection, no deficiencies have been cited. An exit interview was conducted where this report was discussed and provided to Licensee Theresa Lindseth. A Notice of Site Visit has been issued and must be posted for 30 consecutive days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020

LIC809 (FAS) - (06/04)

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