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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407809
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:33:41 PM


Document Has Been Signed on 09/15/2022 04:33 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:THOM, MARY & PETRIE, MEREDITHFACILITY NUMBER:
434407809
ADMINISTRATOR:THOM, MARYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 778-3515
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:14CENSUS: 9DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Meredith Petrie and Mary ThomTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 1 Year inspection. LPA met with Licensee Meredith Petrie and Mary Thom and explained the reason for the inspection. Present during today's inspection were Licensees and nine (9) children, whom two (2) were infant age.
There is an area to post required postings, such as license and notification of parent's rights. The hours of operation are Monday through Friday 6AM to 6PM. There is working phone in the home.

LPA toured the inside and outside of the home with Licensee Meredith. The off-limit areas of the home are garage, dining room, living room, kitchen, family room, sitting room, bedroom 2, and master bedroom. Disinfectant, cleaning supplies, and other items that could pose a risk to the children in care were observed to inaccessible. There are toys and equipment for children. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire drill was conducted on 09/03/2022. Licensee Meredith stated that there are no weapons, such as firearms, stored in the home.

The backyard and the driveway in front of the daycare area is used. The play structure is anchored to the ground. There are toys and equipment for children to play with. There is a pool and a hot tub, which had a locked cover and can withstand the weight of an adult. There were no other bodies of water observed during today's inspection.

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SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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: THOM, MARY & PETRIE, MEREDITH
FACILITY NUMBER: 434407809
VISIT DATE: 09/15/2022
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA provided Licensee Meredith with PIN 20-24-CCP. LPA also informed licensee 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. Licensee will submit sleep log for the C-1 and C-2 and the LIC 9227 for C-1. Licensees understand that infants need to be placed on their back and there cannot be anything in the play yard. Licensee also understands that children need to be transferred to play yard once they fall asleep and would need a doctor's note to have infant placed in a different position. LPA discussed with Licensee Meredith about conducting sleep check every 15 minutes for children under 2 years old.


Licensees does not provide Incidental Medical Services (IMS). LPA did observed that there medication in the bathroom drawer for a child. Licensee stated that the child does not need the medication anymore and will send it back. LPA reminded Licensee that any medication needs to be inaccessible to children and they would need documentation. 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: http://www.ada.gov/childqanda.htm.


--------------------continues on 809 dated 09/15/2022 page 3----------------------
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: THOM, MARY & PETRIE, MEREDITH
FACILITY NUMBER: 434407809
VISIT DATE: 09/15/2022
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------------------continuation on 809 dated 09/15/2022 page 2--------------------

Ten (10) children's files were reviewed during today's inspection. The records reviewed include but not limited to parent's rights. LPA reminded Licensee to ensure that forms is filled out completed, such as the child's name on the form. Licensee will submit additional facility roster to Licensing.

Both Licensees completed Mandated Reporter training on 009/23/2021 and have a valid CPR/1st Aid, which expires on 07/01/2024.

The adults 18 and older living in the home are both Licensees, Licensee Mary's spouse, and Mary's adult child (A-1). All adults have cleared fingerprints. Licensee will submit TB test and LIC 508 for A-1 to Licensing. 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.

Licensees will submit the following:
- Sleep Check for C-1 and C-2
- LIC 9227 for C-2
- updated facility roster
- LIC 508 and TB test for A-1
- updated LIC 279

As a result of this inspection, two Type B citations were issued. Exit interview conducted and report was reviewed with Licensees Mary Thom and Meredith Petrie. 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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/15/2022 04:33 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: THOM, MARY & PETRIE, MEREDITH
FACILITY NUMBER: 434407809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record reviews, the licensee did not comply with the section cited above in 1 out of 1 persons, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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By POC 09/23/2022, Licensees will have C-1's parent fill out form and send proof to Licensing.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record reviews, the licensee did not comply with the section cited above in 2 out of 2 persons, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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By POC 09/23/2022, Licensees will submit proof that sleep check, which include the child's name, date, and time check, for C-1 and C-2 was completed and send proof to Licensing.

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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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