<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001686
Report Date: 04/04/2025
Date Signed: 04/04/2025 12:26:57 PM

Document Has Been Signed on 04/04/2025 12:26 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 BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:TOLBERT, JOSEPHINEFACILITY NUMBER:
384001686
ADMINISTRATOR/
DIRECTOR:		TOLBERT, JOSEPHINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 424-9016
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: DATE:
04/04/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Josephine Tolbert, Robert Sims, and LatoyaTIME VISIT/
INSPECTION 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
On 4/4/2025, Licensing Program Analysts (LPAs) Leong and Naves, along with Licensing Program Manager (LPM) Leung, conducted a scheduled office meeting with Licensee Josephine Tolbert. Latoya Jenkins and Robert SIms were present at this meeting. The meeting took place at the San Bruno Regional Office to review the site visits conducted on 1/28/2025, 2/11/2025, and 2/18/2025.

On 1/28/2025, LPAs Leong and Van attempted to conduct an annual visit, but the licensee did not grant entry into the home after state-issued badges were shown to the licensee. Therefore, LPAs issued a deficiency for inspection authority, which resulted in an immediate $500 civil penalty.

On 2/11/2025, LPAs Leong and Naves conducted an annual visit and were permitted to enter the licensee's home. During that visit, LPAs issued one Type A and nine Type B deficiencies. The Type A deficiency occurred when children used the home's upper level, which is off-limits to them.

On 2/18/2025, LPAs Leong and Naves conducted a plan of correction (POC) visit to follow up on the Type A deficiency cited on 2/11/2025. LPAs observed that the children were using the home's upper level, indicating that the licensee had not corrected the deficiency. Therefore, the LPAs issued a $600 civil penalty for failing to correct the deficiency.

The following Type A deficiency, using the home’s upper level, was discussed. LPAs and LPM informed the licensee that she must immediately stop using the upper level and refrain from using it.

The following Type B deficiencies were discussed with the licensee.

- Where children are less than five years old are in care, stairs shall be fenced or barricaded.

- Documenting emergency disaster drills.

See Page 2

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Hanson Leong
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TOLBERT, JOSEPHINE
FACILITY NUMBER: 384001686
VISIT DATE: 04/04/2025
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
26
27
28
29
30
31
32
Page 2
- Mandated Reporter Training (AB 1207)

- Pediatric cardiopulmonary resuscitation (CPR) and pediatric first aid

- Staff immunization records, including those for influenza, pertussis, and measles.

- Documentation of children’s immunization records

- Form LIC 995A, Family Child Care Home - Notification of Parents' Rights

- Form LIC 627, Consent For Emergency Medical Treatment - Child Care Centers or Family Child Care Homes. Form 700, Identification And Emergency Information Child Care Centers/Family Child Care Homes

- Form LIC 282, Affidavit Regarding Liability Insurance For Family Child Care Home

Overnight care was discussed with the licensee, and she must follow the overnight care regulations, which are listed below.

- The provider shall remain awake whenever children are awake.


- The door to the room where the provider is sleeping as well as the door to the room where the children in care are sleeping shall remain open.
- If the sleeping arrangements are not situated in such a way that the provider can be assured of hearing a child in care wake up, a digital video and audio monitoring device shall be used.
- The monitoring device shall be maintained in good working order at all times.

Type B deficiencies listed above were discussed with the licensee. LPAs and LPM informed the licensee of the importance of addressing the Type A and B deficiencies listed above and complying with the Child Care and Health Safety Code Regulations.

LPAs and LPM informed the licensee that the department would follow up on each deficiency.The deadline to clear the other Type B deficiencies will be on 4/18/2025. LPM also informed the licensee that a LPA may visit her home at a later date to follow up on the deficiencies. If the deficiencies are not cleared during that visit, a civil penalty of $100 per day per violation may be issued.

See Page 3

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Hanson Leong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TOLBERT, JOSEPHINE
FACILITY NUMBER: 384001686
VISIT DATE: 04/04/2025
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
26
27
28
29
30
31
32
Page 3
The Mandated Reporter Training certificate was reviewed and found it to be completed on 4/4/2025

The Pediatric CPR and First Aid course was reviewed, and it was found that the online First Aid course had been completed. The licensee provided proof that she signed up for the Pediatric CPR course on 4/3/2025, but the course was canceled. The licensee provided proof that the Pediatric CPR course was rescheduled for 4/8/2025.

The required children’s forms (LIC 282, LIC 627, LIC 700, LIC 995A, and LIC 9224) in Spanish were given to the licensee. The entrance checklist, LIC 126, was given to the licensee. The entrance checklist outlines the necessary documentation for staff and children's records.

The Mandated Reporter Training deficiency was cleared during today’s visit

The use of the off-limits area deficiency was cleared during today’s visit

Exit interview conducted and report was reviewed with the Licensee, Josephine Tolbert.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Hanson Leong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4