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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413739
Report Date: 03/13/2020
Date Signed: 06/17/2020 12:04:49 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:BAXTER, KRISTIN & JEFFREYFACILITY NUMBER:
434413739
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
03/13/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Kristin & Jeffrey BaxterTIME COMPLETED:
02:20 PM
NARRATIVE
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LPA Janet Tse met with licensees Kristin and Jeffrey Baxter for a Plan of Correction inspection and also to deliver an amended report for the inspection conducted on 03/06/2020. LPA explained the nature of today's inspection to licensees. LPA observed four children with licensees in the home today. At arrival, LPA observed a child was in the off limits master bedroom with licensee Jeffrey Baxter. Licensing was not notified of the change of usage of the off limits master bedroom for child care.

LPA observed the bouncers have been removed from the premises and licensees stated they are no longer using the bouncers and similar items for the day care children. Request for live scan service form for the tenant residing in the cottage (YZ) was received by LPA on 03/09/2020; and the tenant's fingerprint clearances are cleared and associated to the facility per information from the Licensing Information System.

Licensees have provided inaccurate information about the tenant residing in the cottage during the inspection on 03/06/2020. An amended report and a new civil penalty assessment with the current tenant's information were reissued today. Cleared Plan of Corrections letter was provided to licensees.

LPA obtained a copy of the roster of the children today.

Deficiency was cited. Notice of site visit was issued and must be posted for 30 days. Licensee was advised that the increase of capacity will not be approved until deficiency is corrected and a revised fire clearance report for the entire home including the cottage is received by Licensing.

This is an amended report for the inspection conducted on 03/13/2020. This amended report was delivered and signed on 06/17/2020.. Due to COVID 19, a copy of this Licensing report with LPA's signature alone will be emailed to Licensee; and in lieu of Licensee's signature, a read receipt of the email will serve as acknowledgement of receipt of this Licensing report by Licensee.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020
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: BAXTER, KRISTIN & JEFFREY
FACILITY NUMBER: 434413739
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2020
Section Cited

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Alterations to Existing Buildings or Grounds. Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:...Any change from an area of the family child care home previously identified as "off limits" to an area where care and
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supervision will be provided to children in care.
This requirement was not met as evidenced by:
LPA observed a child was in the off limits master bedroom with licensee Jeffrey Baxter. Licensing was not notified of the change of usage of the off limits master bedroom for child care./ This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2020
LIC809 (FAS) - (06/04)
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