444409066-3-22-2023-07-CC-CNEN-CQ6PTJ-20230322113601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444409066
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:36:18 AM

Document Has Been Signed on 03/22/2023 11:36 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: 3	DATE:	03/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Patricia Gilbertson		TIME COMPLETED:	11:45 AM

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's Spouse (Tom) and toured both indoors and outdoors during the inspection. Upon arrival, there were two (2) preschool-age children, one (1) school-age child, and the Licensee present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings near the entrance to the home and the hours of operation are Monday – Thursday, 7:30AM-5:00PM. The Licensee states that adults, over the age of 18, residing in the home are: herself and her spouse (Tom). All adults residing in the home have Criminal Background Check Clearance and proof of negative tuberculosis (TB) test. The 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 and observed the last drill was not documented. LPA reminded the Licensee that drills must be documented for review during annual inspections. There is a fully charged 3A40BC fire extinguisher, functioning smoke detector and carbon monoxide detector. The 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. There are no weapons or firearms in the home. 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

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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: 03/22/2023

NARRATIVE

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Indoor areas of the home were inspected by the LPA and observed to be clean, orderly, and safe for the day care children. Off-limits inside the home include: entire second floor, pantry, workout room, and laundry room. The Licensee has a waiver for wood-burning stove and LPA observed it is cool to the touch and not in use while day care children are present. During today's inspection, LPA observed the children eating breakfast/snack, playing with toys, and practicing letter recognition with flash cards. The Licensee states that she serves breakfast, lunch, and AM/PM snack to the children in care. The bathroom in the home is clean, sanitary, and operable. There is a working telephone in the home. LPA reminded the Licensee that stairs must be barricaded when children younger than five (5) years old are in care.

The backyard area of the home was inspected and observed to be fenced in. The playground area for children is located down the patio stairs and LPA observed baby gate for the stairs was not closed. There is sufficient play-equipment and supplies for the children that are in good condition and age-appropriate. LPA observed two bird baths located outside, accessible to children. LPA let the Licensee know that bodies of water shall not be accessible to children, including bird baths. The Licensee states due to inclement weather the backyard has not been utilized by the children. Off-limit areas outside of home include: game room, storage room, and right side yard. There are two restrooms located outside equipped with RV style toilets that the Licensee states are sanitized after each use and emptied once per week. The Licensee states they are for ease of getting children to the restroom faster than the one in the home as needed.

Three (3) children’s files and the Licensee's file were reviewed and all required documents were present. The Licensee has current CPR/First-Aid that expires 4/2024 and current Mandated Reporter Training that expires on 4/8/2024. LPA reminded that training must be renewed by all staff every 2 years.

The Licensee states that her spouse picks-up school-age children from Vine Hill Elementary after school is dismissed. LPA observed that Tom has a current CA drivers license (exp: 8/12/2024) and the vehicle has current registration and valid insurance. LPA reminded 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.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/22/2023 11:36 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: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(3)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above for stairs located outside on the patio with observed baby gate that is not closed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	The Licensee shall ensure that baby gates are closed at all times when children under five (5) years of age are present, even while not using outside play area as children are using patio as a walkway. The Licensee will submit written attestment for hours when baby gates will be closed and their locations.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/22/2023 11:36 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: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)1

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above as fire/disaster drills were not documented, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	The Licensee will conduct a fire/disaster drill by 3/31/2023 and submit copy of the drill log to the Department. LPA provided the Licensee with a new fire/disaster drill log as the copy reviewed today was full.

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: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 03/22/2023 11:36 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: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(5)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observtion and interview, the licensee did not comply with the section cited above in the backyard area where two bird baths filled with water were located accessible to children, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/23/2023
	Plan of Correction
1 2 3 4	The Licensee will remove the bird baths from the backyard area and ensure that bodies of water are not accessible to the children. The backyard has not been used due to inclement weather and the Licensee states that the bird baths are usually empty when it is not raining. The bird baths were moved out of the children's outdoor play area during todays inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

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