444409066-3-8-2022-07-CC-CNEN-CCBP5G-20220308100043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444409066
Report Date: 03/07/2022
Date Signed: 03/08/2022 10:00:53 AM

Document Has Been Signed on 03/08/2022 10:00 AM - It Cannot Be Edited

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: 5	DATE:	03/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Patricia Gilbertson		TIME COMPLETED:	01:00 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), Cortney Nelson, met with Licensee, Patricia Gilbertson, for an unannounced Required- 1 Year Inspection. LPA was granted access to the home by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were 5 children (preschool-aged), 2 assistants (Mariel Hooks & Stephanie Wagner),and spouse (Tom Gilbertson) present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings in day care area of the home. Hours of operation for the facility are Monday – Thursday, 7:30AM-5:00PM. Licensee states that adults, over the age of 18, residing in the home are: herself, her spouse (Tom), and her adult daughter (Mariel Hooks). All adults residing in the home have Criminal Background Check Clearance and signed Criminal Record Statements (LIC508). Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. LPA reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The last fire/disaster drill was conducted in December 2020, which is compliant with the six-month requirement for homes. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke detector and carbon monoxide detector. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. The Licensee states that there are no weapons or firearms in the home, however her husband is a peace officer and keeps his weapon in his personal vehicle (Ford Taurus) that is not used to transport children.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

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: 03/07/2022

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes, Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

Indoor areas of the home were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Off-limits areas of the home (indoors): entire upstairs and gym room. There is a wood burning stove in the living room with a waiver not be used while children are present, which was cool to the touch and safe for children. Licensee understands that she cannot use the fireplace units during day care hours. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. Drinking water is readily available for children in the facility via disposable cups labeled with the children’s names. All food is provided by the facility and children do not bring food from home. The bathroom in the home is clean, sanitary, and operable. LPA advised Licensee that currently paper towels should be used to dry children's hands for COVID preventative measures. The Licensee has a working telephone in the facility. Stairs inside the home leading to the second floor were barricaded appropriately to keep day care children safe during the inspection.

The backyard area of the home was inspected. LPA observed sufficient play-equipment and supplies for the children that are in good condition and age-appropriate. Small outdoor bathroom for children is located near the playground and is safe and operable for children to use. Off-limit areas outside of home include: both side yard areas and storage room. No outdoor bodies of water were observed during todays inspection. Stairs leading to the play area of the back yard are not barricaded.

Licensee states that she does not currently care for infants, only children ages 3 and up. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

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: 03/07/2022

NARRATIVE

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5 children’s files were reviewed during todays inspection and all required documents were present, including LIC282 & LIC9150. All children's files additionally included LIC9166 for nebulizer use in care. LPA advised Licensee that if a child does not have a nebulizer, do not have parent complete the document, as Licensee states no children in care require a nebulizer.

3 staff files (Licensee & 2 Assistants) were reviewed. All staff files were missing immunization records (MMR, tDap, Flu), Mandated Reporter certificates, and TB test. CPR/First-Aid expired on 12/2020.

Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. The Licensee states that her spouse transports day care children and picks up school-aged children from Vine Hill Elementary School. Vehicle to transport children is Ford Expedition plate# 8FTS077 equipped with four booster seats. LPA checked and spouse has valid drivers license, expires 8/2024. LPA advised that because Spouse is with children alone, he needs CPR/First-Aid certification as well as Mandated Reporter certificate and immunization record. LPA additionally advised Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Patricia Gilbertson.

As a result of todays inspection deficiencies were cited, see 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2022 10:00 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above for all 4 staff present which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2022
	Plan of Correction
1 2 3 4	Licensee will submit proof of immunization for tDap, MMR, and flu by 4/7/2022. Written statement declining flu shot is accepable as well.

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above for all 4 staff present, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2022
	Plan of Correction
1 2 3 4	Licensee will submit proof of completed CPR/First-Aid for all staff who are alone with the children by 4/7/2022.

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC809 (FAS) - (06/04)

Page: 5 of 5

Document Has Been Signed on 03/08/2022 10:00 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102369(b)(9)

(9) Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above for all 4 staff present, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2022
	Plan of Correction
1 2 3 4	Licensee will submit proof of TB test for all staff present at the home by 4/7/2022.

Type B

Section Cited

HSC

1596.8662(b)(1)

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day 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 following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above for all staff 4 present, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2022
	Plan of Correction
1 2 3 4	Licensee will submit Mandated Reporter certificate for all staff by 3/21/2022.

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC809 (FAS) - (06/04)

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