444415854-3-14-2025-07-CC-ALUZ-DERSDP-20250314134728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444415854
Report Date: 03/14/2025
Date Signed: 03/14/2025 01:47:51 PM

Document Has Been Signed on 03/14/2025 01:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	GOLDMAN LISA		FACILITY NUMBER:	444415854
ADMINISTRATOR/ DIRECTOR:	GOLDMAN LISA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 427-1159
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 18	CENSUS: 12	DATE:	03/14/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:55 AM
MET WITH:	Lisa Goldman		TIME VISIT/ INSPECTION COMPLETED:	02:05 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	At 10:55AM, Licensing Program Analyst (LPA) Angela Luz entered the facility and met with fingerprint cleared staff (S3). Licensee Lisa Goldman arrived at the facility at 11:05AM and LPA informed them that the purpose of the visit was to conduct an unannounced annual RANDOM inspection. Present for this inspection was 2 infants, 10 preschool aged children, 2 fingerprint cleared staff, and 1 fingerprint cleared adult. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday - Friday 8:30AM - 4PM. Facility: The OFF LIMIT AREA is Licensee’s home building and attached garage. ON LIMIT AREAS are the home studio, outdoor bathroom, front yard and backyard. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. The outdoor play area is free from defects or dangerous conditions and is fully fenced. There is a self latching gate in the pathway from the front yard to the backyard. The front yard gate has a barrel bolt. There are stairs leading up to the outdoor bathroom at are barricaded. Most of the children’s time in care is spent outdoors and children arrive in weather appropriate clothing. Licensee states that they have extra clothing. The home is neat and clean with heating and ventilation for safety and comfort. The ISOLATION AREA is the front yard. There have been no changes from the areas previously identified as OFF LIMITS or alterations to existing building or grounds. There are no bodies of water. All hazardous materials and toxins are kept out of the reach of children. Licensee states that there are no firearms in the home. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. LPA reminded that fire extinguishers should be serviced once a year. *Page 1 of 4*

Belinda Devall	TELEPHONE: (408) 324-2128
Angela Luz	TELEPHONE: (916) 931-9802
	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 7

Document Has Been Signed on 03/14/2025 01:47 PM - 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOLDMAN LISA	FACILITY NUMBER: 444415854
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 LPA record review and Licensee interview, S2 is missing proof of a negative TB test. The licensee did not comply with the section cited above in 1 out of 3 personnel which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2025
	Plan of Correction
1 2 3 4	By plan of correction due date 3/28, Licensee will submit proof of S2 negative TB test.

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.

Belinda Devall	TELEPHONE: (408) 324-2128
Angela Luz	TELEPHONE: (916) 931-9802
	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

Page: 2 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOLDMAN LISA	FACILITY NUMBER: 444415854
	VISIT DATE: 03/14/2025

NARRATIVE

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Care and Supervision: There are ample age-appropriate toys that appear to be safe and in good condition. When children have challenging behaviors, Licensee talks with the child to find the need and the why of the emotion. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, interference with eating, intimidation, or other actions of a punitive nature. Children are treated with dignity, receive safe, healthful, and comfortable accommodations.

Play yards do not hinder entrance or exit to and from the space where infants are sleeping. Mattresses for the play yards were missing. LPA reminded that mattresses that are made for the dimensions of the play yard are required. The pads in the play yards are firm and covered with a fitted sheet that is appropriate, fits tightly, and overlaps the underside of the pad. Each infant’s bedding is used for them only and cleaned daily or before use by another infant. There are no loose articles and objects, bumper guards or objects hanging above or attached to the side of the cribs or play yards. LPA gave copies of PIN 20-24-CCP and Title 22 Section 102425 Infant Safe Sleep with Licensee. Licensee understands Infant Safe Sleep requirements.

Records: The Licensee CPR and First Aid certificate is current and expires 10/2/26. Licensee Mandated Reporter Training for Child Care Providers is current and expires 10/9/26. Licensee was reminded of Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file. The Licensee conducts and documents fire and disaster drills every six months, last drill was on 2/13/25. A current copy of the facility roster was viewed, and a copy was obtained. Licensee carries liability insurance for the daycare that expires on 6/12/25. Entrance checklist for Family Child Care Home was provided and licensee was reminded of documents to be posted in a prominent, publicly accessible area of the facility.

LPA reviewed six (6) children files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization records. Documentation of infant sleep checks every 15 minutes that notate any signs of distress was missing. LPA reminded that documentation of 15 minute infant sleep checks are required for infants 0-24 months. Licensee has documentation to administer medication for child 1 (C1). LPA, Luz reviewed three (3) staff (S1-S3) files for the following records: Employee rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunization records, and required training. Staff 2 (S2) is missing proof of a negative TB test.
***Page 2 of 4***

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Angela Luz	TELEPHONE: (916) 931-9802
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

Page: 5 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOLDMAN LISA	FACILITY NUMBER: 444415854
	VISIT DATE: 03/14/2025

NARRATIVE

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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

*Page 3 of 4***

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Angela Luz	TELEPHONE: (916) 931-9802
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

Page: 6 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOLDMAN LISA	FACILITY NUMBER: 444415854
	VISIT DATE: 03/14/2025

NARRATIVE

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During the exit interview, the LICENSEE, Lisa Goldman, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Megan's Law was checked on 3/4/25.

During today's inspection, 1 Type B deficiencies are issued on attached page 809-D.

1 Staff (S2) missing proof of negative TB test.

2 advisory notes are issued.

Play yards shall have mattresses that are made specifically for the size of the play yard in which they are placed.
15 minute sleep check documentation is required for infants 0-24 months.

Appeal rights were provided.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Lisa Goldman.

***Page 4 of 4, End of Report***

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Angela Luz	TELEPHONE: (916) 931-9802
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

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