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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001686
Report Date: 01/28/2025
Date Signed: 01/28/2025 10:23:23 AM

Document Has Been Signed on 01/28/2025 10:23 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
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: 14CENSUS: DATE:
01/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Josephine TolbertTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
NARRATIVE
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On 1/28/2025, Licensing Program Analysts (LPAs) Leong and Van conducted an annual inspection. LPAs rang the doorbell, but there was no response. While the LPAs were preparing their report, LPAs noticed the licensee opening the window blind. When LPAs rang the doorbell again, the licensee opened the window to speak with LPAs. LPAs introduced themselves and showed her their state employee issued identification. The licensee stated, “I’m not ready for an inspection and can’t let you in.” She added, “I’ll call the department to set up a scheduled visit.” LPAs explained that the department needed to conduct the inspection at that time, but the licensee insisted, “You can’t come in.”

Due to the licensee's refusal to grant access to the LPAs, the facility will receive a Type A violation, and a $500 civil penalty.

Also, LPAs Leong and Van provided a copy of this licensing report in the licensee's mailbox dated 1/28/2025 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A Notice of Site Visit and LIC 809D were dropped in the licensee’s mailbox, and both must remain posted for 30 days.

Today’s report and the facility's appeal rights were dropped off in the licensee’s mailbox.

Licensee’s signature was not obtained.

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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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Document Has Been Signed on 01/28/2025 10:23 AM - It Cannot Be Edited


Created By: Hanson Leong On 01/28/2025 at 09:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TOLBERT, JOSEPHINE
FACILITY NUMBER: 384001686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/29/2025
Section Cited
CCR
102391(a)

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102391 Inspection Authority of the Department
(a) Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, the regulations adopted by the Department governing family child care homes, and in accordance with Section 102396.

This requirement is not met as evidenced by:
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The licensee must review and familiarize with the Title 22 Inspection Authority regulations, under Child Care Regulations Section 102391 and develop a written plan to prevent future incidents. Furthermore, an office visit may be scheduled at a later date.
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Based on interview and observations, the licensee did not comply with the section cited above. After the LPAs introduced themselves and showed their department-issued IDs, LPAs explained the purpose of their inspection. However, the licensee declined to grant them entry into the home, which poses an immediate health, safety or personal rights 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.
SUPERVISOR'S NAME:Garfield Leung
LICENSING EVALUATOR NAME:Hanson Leong
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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