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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413551
Report Date: 05/15/2019
Date Signed: 05/15/2019 12:52:09 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:ROEBBERT, SHEILAFACILITY NUMBER:
434413551
ADMINISTRATOR:ROEBBERT, SHEILAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 224-7397
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:14CENSUS: 10DATE:
05/15/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Sheila RoebbertTIME COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analysts (LPA) Shannel Reed conducted an unannounced annual/ random inspection to the home today. LPA met with Licensee, Sheila Roebbert, and explained the nature of today's visit. Present in the home were 10 daycare children (preschool age) with the Licensee and her Assistant, Cynthia Hall, Licensee’s spouse- Franz Roebbert and her adult son Tyler Roebbert. Days and hours of operation are Monday - Thursday from 9AM- 12PM (September – May). The Licensee states that she and her spouse- Franz , adult son- Tyler and minor daughter live in the home. LPA observed the Licensee’s CPR/ First Aid card which expires on 08/30/20.
LPA toured the indoor and outdoor areas of the home during today's visit. LPA reviewed and obtained current Child Care Facility Roster. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Off limit areas inside the home: entire upstairs level, entry level: full bathroom, 2 bedrooms and Living Room. Off limit areas outside the home: right side of the backyard. LPA observed no bodies of water. The Licensee has two small dogs, which she states she keeps in the off-limits bedroom downstairs and separate from the children in care. (Dogs: Cookie- Female- 5 years old & Buster-Male-10 years old). The dogs are fully vaccinated.
LPA observed a fully charged 3A40BC fire extinguisher. LPA observed and tested an operational smoke and carbon monoxide detector. The Licensee stated that there are no firearms in the home. LPA observed detergents, cleaning compounds are inaccessible to children.
A review of Staff records indicates that all persons that require a caregiver background check have received criminal record and child abuse index clearance or exemption. LPA informed Licensee of the applicable civil penalties for any adult who has not received fingerprint clearances, is not associated to the license and who comes in contact with or provides 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.
REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 05/15/19):
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Shannel ReedTELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019
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: ROEBBERT, SHEILA
FACILITY NUMBER: 434413551
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2019
Section Cited
HSC
1597.622
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Commencing September 1, 2016, a person shall not be employed or volunteer at a familyday care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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The Licensee will submit proof of immunity against Pertussis and Measles for herself and Assistant, Cynthia Hall by the POC due date of June 14, 2019.
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This requirement is not met as evidenced by: LPA observed that the Licensee and her Assistant, Cynthia Hall do not have the required immunizations against Pertussis and Measles on file. This poses a potential health and safety risk to children in care.
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Type B
06/28/2019
Section Cited
HSC
1596.8662(b)
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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years.
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Licensee and her Assistant, Cynthia Hall shall take the mandated reporter training and will submit a copy of the certificates of completion to LPA by the POC due date of June 28, 2019.
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This requirement is not met as evidenced by: LPA observed that Licensee and her Assistant, Cynthia Hall have not completed the mandated reporter training (AB1207) as of May 15, 2019. Licensee understands this is a potential risk to the children in care and a deficiency to the Health and Safety regulations.
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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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Shannel ReedTELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019
LIC809 (FAS) - (06/04)
Page: 3 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: ROEBBERT, SHEILA
FACILITY NUMBER: 434413551
VISIT DATE: 05/15/2019
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (REPORT DATED 05/15/19):
LPA observed that the Licensee and her Assistant, Cynthia Hall, have not completed the required Mandated Reporter Training (AB1207). Licensee and her Assistant, Cynthia Hall, do not have the required immunization's against Pertussis and Measles on file. The Licensee and her Assistant have decline statements on file for influenza. LPA reviewed six (6) children’s files. LPA observed that all children have the required immunization records, Identification and Emergency Contact form (LIC700) and additional required documentation.
Supervision of children was discussed with the Licensee. Licensee stated that she is present 100 percent of the time. The Licensee states that she does not transport children via vehicle and she understands the car seat laws and that children cannot be left in parked vehicles unattended at any time.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov. The Mandated Reporter Training (AB1207) can be completed at the website listed, http://www.mandatedreporterca.com. Handout for the Mandated Reporter Training was provided.

Title 22 deficiencies were cited on the subsequent page of this report.

A NOTICE OF SITE VISIT WAS ISSUED, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Shannel ReedTELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3