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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444406185
Report Date: 07/18/2019
Date Signed: 07/18/2019 03:08:38 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:HANSEN, SIGRIDFACILITY NUMBER:
444406185
ADMINISTRATOR:HANSEN, SIGRIDFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 439-8721
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:14CENSUS: 3DATE:
07/18/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sigrid (Kirsten) Hansen TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mahvash Behbood conducted an unannounced Annual Random visit. The purpose of today’s visit explained. Present also were 3 children (one infants, and 2 just turned 2). Hours of operation are Monday - Friday, 7 AN to 5:30 PM. Living in the home is licensee, occasionally her adult children stay with her. All adults or other individuals who require caregiver background checks have received criminal record and child abuse index clearance or exemptions. Licensee's CPR and First Aid are current and expire in 11/2019. Licensee has copies of the required immunization as well as California Mandated Reporter Training. Licensee is aware that the Mandated Training must be completed every 2 years.

LPA toured the indoor and outdoor areas of the home during today's visit. Stairs leading to second floor is gated. LPA reviewed a current Child Care Facility Roster and Fire/Disaster Drill Log during today's visit. Last fire drill was conducted in July of 2019. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. Home is equipped with central heating. Off limit areas in the home are the entire second floor, garage and laundry room.

LPA observed a fully charged 2A10BC fire extinguisher, smoke/carbon monoxide detectors. There is no bodies of water. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, poisons, medications, are out of reach and inaccessible to children.

Effect of lead exposure poster was provided to licensee and for their information and to share with children. Discussed also was safe sleep.

No deficiencies cited, exit interview conducted, and a copy of this report was provided to the Licensee.

SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
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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