444409066-5-16-2019-07-CC-ZHAM-BC8V9U-20190516161454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444409066
Report Date: 05/16/2019
Date Signed: 05/16/2019 10:47:30 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:	GILBERTSON, PATRICIA		FACILITY NUMBER:	444409066
ADMINISTRATOR:	PATRICIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 438-5437
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	14	CENSUS: 10	DATE:	05/16/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Patricia Gilbertsons		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Zaid Hakim conducted an Unannounced Annual / Random Inspection at the facility today. Upon arrival, LPA observed ten (10) preschool age children engaging in daily activities and met with Ms. Patricia Gilbertson, Licensee. The Licensee, her spouse, and one other adult are the only adults that reside in the home and all maintain valid background clearance. The days and hours of operation are Monday through Thursday 7:30am to 5:30pm. LPA observed required postings; including but not limited to the License to operate, Emergency Disaster Plan (LIC 610) and Notification of Parents Rights (PUB 393). The facility is licensed for a maximum capacity of 14 children and the Licensee stated that she understands capacity options. At the time of the inspection LPA observed that the Licensee is in compliance with capacity and ratio requirements. LPA toured the facility inside and out and observed all indoor and outdoor activity areas. LPA observed door locks and barricade gates securing off limit areas which include the kitchen room, laundry room, and a portion of the backyard. The facility is equipped with at least one functioning smoke detector, one carbon monoxide detector, first aid supplies, and at least one 2A10BC fire extinguisher. The Licensee was reminded that fire safety items and fire extinguishers should be maintained at least once every 12 months. Toxic cleaning supplies and other items that pose a danger to children are securely stored in inaccessible locations. The home has sufficient and safe toys, equipment, and supplies. The outdoor play area was observed to be safe and equipped with age appropriate toys and equipment. The Licensee stated that there are no weapons or firearms in the home, no fireplaces in the home, and no bodies of water on the premises. There is a wood burning stove in the home, that is secured and not opened that the licensee has obtained a waiver for. LPA observed the outdoor play area which was equipped with secure perimeter fencing. The Licensee stated that the sand box is covered at night and play equipment and structures are monitored regularly per children's safety. LPA advised that licensing forms and all other information can be found at: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing CONTINUATION ON FOLLOWING PAGE (PAGE #2 - REPORT DATED 05/16/2019):

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Zaid Hakim	TELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2019

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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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: GILBERTSON, PATRICIA	FACILITY NUMBER: 444409066
	VISIT DATE: 05/16/2019

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/16/2019):

The Licensee serves and meals snacks to the children and the Licensee stated that food served to children are communicated to parents regularly via parent notifications. The Licensee stated that she is aware of all food allergies or dietary restrictions of the children. The kitchen and food preparation / service areas were observed to be clean and fully furnished with supplies. The Licensee stated that there are no bouncers in the home and understands that bouncers may not be used in family home day cares. The Licensee stated that she understands that children that arrive to the facility in car seats must be removed from car seats upon entry. LPA observed cots, pillows, pack and plays, and blankets for napping. LPA observed all furnishings used by children to be safe and in good condition. LPA and the Licensee discussed safe sleep for infants in care.

The Licensee maintains an accurate roster of enrolled children. The Licensee maintains valid CPR / First Aid training, through an approved vendor, which expires in 12/2020. The Licensee understands that there must be at least one staff on site with Pediatric CPR / First Aid at all times. Emergency disaster drills are done as required, last of which was completed in 12/2018. LPA and the Licensee discussed emergency disaster procedures in the event of a natural or man-made disaster. LPA and the Licensee discussed emergency information regarding the children in care, safety in times of crisis, home surveillance systems in common areas, and emergency supplies maintained in the home, and payment of Licensing fees. The Licensee stated the facility does not take off site field trips and the Licensee does not provide transportation.

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. LPA also reminded The licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide 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.

CONTINUATION ON FOLLOWING PAGE (PAGE #3 - REPORT DATED 05/16/2019):

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Zaid Hakim	TELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2019

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: GILBERTSON, PATRICIA	FACILITY NUMBER: 444409066
	VISIT DATE: 05/16/2019

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 05/16/2019):

LPA reminded the Licensee of the new immunization requirement (pertussis, measles, and flu vaccines) for all staff that work directly with the children and the required "Mandated Reporter" training that all staff will be required to complete starting January 1, 2018.

LPA referred the Licensee to the Department website for additional information on the online training:http://www.mandatedreporterca.com/
LPA confirmed at the time of the inspection that the Licensee has completed this training.

LPA and the Licensee discussed children making noise in the back yard while playing during operating hours and parents parking in the neighborhood during pick up times. LPA advised the Licensee that children being prohibited from playing outside or from making noise while playing, may potentially constitute a personal rights violation. LPA advised that parents parking in the neighborhood to pick up and drop off children is not a licensing concern or issue as it pertains to the Title 22 regulations.

A Notice of Site Visit has been issued and must remain posted for 30 consecutive days.

No Deficiencies have been cited as a result of today's inspection.
Exit interview conducted with Ms. Patricia Gilbertson, Licensee

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Zaid Hakim	TELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2019

LIC809 (FAS) - (06/04)

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