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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384001686
Report Date: 08/31/2021
Date Signed: 08/31/2021 09:50:18 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2021 and conducted by Evaluator Leslit Tapia-Mandujano
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20210630094408
FACILITY NAME:TOLBERT, JOSEPHINEFACILITY NUMBER:
384001686
ADMINISTRATOR:TOLBERT, JOSEPHINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 424-9016
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY:14CENSUS: 2DATE:
08/31/2021
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Josephine TalbortTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility Infested with pests.
INVESTIGATION FINDINGS:
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On 8/31/21, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced inspection and met with licensee, Josephine Tolbert. Purpose of the inspection was explained, and it was to report the investigations finding for above allegations. Complaint was received by the Department on 6/30/21. Present in the home are licensee and two children (one infant and one preschool age). LPA inspected the home for health and safety hazards.

During the Investigation, LPA conducted file review, interviews with licensee, and interview with parents. On 7/09/21, LPA interviewed licensee and she confirmed she has put out traps for pests.

Based on LPA’s observations, interviews and record review which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1, are being cited. Please refer to 9099D for more information.

After today’s visit, an exit interview was conducted with licensee, Josephine Tolbert. A copy of this report will be emailed to josephinesdaycare@outlook.com with Appeal Rights and Procedures. This report is public and can be reviewed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 05-CC-20210630094408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TOLBERT, JOSEPHINE
FACILITY NUMBER: 384001686
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited
CCR
102417(g)
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102417(g) Operation of a Family Child Care Home:"The home shall be free from defects or conditions which might endanger a child..." This requirement is not met as evidence by:
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Per Licensee, traps were placed and issue has been resolved.
Defeciency was cleared on 8/31/21.
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Based on LPA interview with licensee and parents, there has been traps put out for pests in the home. This poses a potential health and safety hazard risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
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