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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444406185
Report Date: 08/26/2021
Date Signed: 08/26/2021 03:33:06 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: 6DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Sigrid HansenTIME COMPLETED:
03:40 PM
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#2 Licensing Program Analysts (LPAs) Cortney Nelson and Marilou Monico conducted an unannounced Required - 1 Year inspection. LPAs met with Licensee, Sigrid Hansen, and explained the purpose of today's visit. Also present in the home were six daycare children including three infants and three preschool age. Licensee is the only adult residing in the home. The daycare is open Monday thru Friday from 7:00 AM to 5:30 PM.

The indoor and outdoor areas were inspected. LPAs observed a fully charged 3A40BC fire extinguisher, working smoke detector, functioning carbon monoxide detector, barricaded stairs, and no bodies of water. Off limit areas in the home: entire upstairs, garage, and laundry room. Off limit areas outside the home: barricaded areas of the backyard, both side yards, and locked storage shed. Cleaning compounds, sharp objects, and other similar items were stored inaccessible to children. Licensee maintains a current children's roster. The last fire/disaster drill was conducted in August 2, 2021. Per licensee, there are no weapons in the home. Six children's files were reviewed. Licensee has current Pediatric CPR/First Aid certification with an expiration date of September 20, 2021. LPAs obtained a copy of children's roster during the inspection.

LPAs discussed Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years. Mandated Reporter Training can be accessed at www.mandatedreporterca.com. Licensee's Mandated Reporter Training expires on May 27, 2022. AB 633 was discussed with Licensee. Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov.
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SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2150
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: 408-334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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: HANSEN, SIGRID
FACILITY NUMBER: 444406185
VISIT DATE: 08/26/2021
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LPAs reviewed with Licensee and provided her a copy of Safe Sleep Regulations (PIN 20-24-CCP).

A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Incidental Medical Services (IMS) was discussed. Licensee stated that she's not planning to provide IMS at this time.

Licensee was advised to update the following forms and submit to Licensing by September 27, 2021:
1) Facility Sketch (LIC 999A)
2) Emergency Disaster Plan (LIC 610A)

As a result of this inspection, there were no deficiencies cited.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2150
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: 408-334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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