444416379-7-15-2021-07-CC-KGOL-C4XQBK-20210715120141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444416379
Report Date: 07/15/2021
Date Signed: 07/15/2021 12:01:53 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:	BALLA, GUSTAVO AND SARA		FACILITY NUMBER:	444416379
ADMINISTRATOR:	BALLA, GUSTAVO AND SARA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 588-4225
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	14	CENSUS: 6	DATE:	07/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Balla, Gustavo and Sara		TIME COMPLETED:	12:30 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) Goodell met with licensees, Gustavo, for the purpose of an Unannounced Annual Random Inspection. Hours of operation are Monday- Friday, 8:30 am- 1:00pm. During inspection, LPA observed six children present with licensees and three staff. All individuals subject to criminal background review have obtained a criminal record clearance. Inspection was conducted in all areas accessible to children. Off-limits areas include: the entire upstairs, garage, tree house, and the detached unit (not a separate parcel number). LPA verified current phone number and email are current. LPA also observed a 3A40BC fire extinguisher, smoke and carbon monoxide detectors. No weapons in the home. LPA observed a hot tub located, in the off-limits back yard area that has a weight bearing cover and four latch ties. Licensee acknowledged latches remain secured and area inaccessible to children in care at all times during days and hours of operation. During inspection LPA learned and observed the pool located in the off-limits outdoor area listed on facility sketch has been filled with grass. Licensee will submit updated outdoor sketch. Licensee acknowledged that 100% supervision is required in unfenced area. LPA observed cleaning compounds, medication and knives are stored inaccessible to children. Children's records were reviewed. Individual Infant Sleeping Plan (LIC9227) and sleeping log for infants under the age of 12 month was discussed. LPA also observed fire drill log and children roster maintained. Preventative health training, current pediatric CPR and first aid certification was verified and expires 5/2023. Report continues on LIC 809-C

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kristal Goodell	TELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

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: BALLA, GUSTAVO AND SARA	FACILITY NUMBER: 444416379
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/16/2021 Section Cited	1 2 3 4 5 6 7	Application for Initial License. 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 due to during review of staff files LPA observed staff #1 did not have proof of current T.B. on file which poses a potential risk on file
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kristal Goodell	TELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

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: BALLA, GUSTAVO AND SARA	FACILITY NUMBER: 444416379
	VISIT DATE: 07/15/2021

NARRATIVE

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During inspection LPA conducted file reviews for all assistant present. LPA observed staff #1 did not have proof of TB test on file which poses a potential risk to children in care. Licensee acknowledged 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. Licensee stated proof will be submit proof to LPA by X

All Inclined sleepers are prohibited per: PIN 19-16-CCP was issued and discussed. Lead Flyer Requirement and Safe Sleep Awareness were issued discussed. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, forms, self-assessment guides, legislation and regulation information. PIN 21-08-CCP and COVID-19 UPDATE Guidance: Child Care Programs and Providers were discussed.

Title 22 Deficiency cited. LPAs reviewed report with the licensee and provided copies. An exist interview was conducted. The Notice of Site Visit issued and must remain posted for 30 days. Appeal Right also issued and discussed.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kristal Goodell	TELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

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