434405879-8-19-2021-07-CC-JCRZ-C62N9D-20210819101547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434405879
Report Date: 08/19/2021
Date Signed: 08/19/2021 10:16:02 AM

Document Has Been Signed on 08/19/2021 10:16 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	SELBO, KRISTINE		FACILITY NUMBER:	434405879
ADMINISTRATOR:	SELBO, KRISTINE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 224-7616
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 8	DATE:	08/19/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:55 AM
MET WITH:	Kristine Selbo		TIME COMPLETED:	10:30 AM

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) Janette Cruz met with Kristine Selbo, Licensee, for an unannounced Required – 1 year annual inspection. LPA explained the purpose of the visit and was granted access to the home by the Licensee. LPA also observed two adult assistants, (Marleen Capps, Christina Gianossa) and eight children (2 infants and 6 preschool) in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements during today's inspection. LPA observed the required postings, including the facility license, located in the living room of the home. The home has a working telephone (408) 224-7616. Days and hours of operation are Monday - Friday from 7:30AM to 5:30PM. The Licensee, her spouse, Steve Selbo, daughter, Jordyn Alexander and son, Jason Alexander are the adults residing in the home. The Licensee's CPR and First Aid on file expires on 02/10/2022. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 6/18/21. The Licensee has the required vaccinations (MMR, Tdap, & flu). The Licensee’s Mandated Reporter Training for Child Care Workers on file expires on 03/09/2023. LPA observed that both adult assistants have current mandated reporter training and CPR/first aid certificates on file. LPA reviewed eight children's files and observed current and updated Identification and Emergency Information (LIC 700) and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. The Licensee states that a child will be isolated in the kitchen area if needed to because of illness or communicable disease. LPA discussed the new “Safe Sleep” regulations with the Licensee and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee. REPORT CONTINUED ON FOLLOWING PAGE #2 - REPORT DATED 08/19/2021):

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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 3

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: SELBO, KRISTINE	FACILITY NUMBER: 434405879
	VISIT DATE: 08/19/2021

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

LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly with heating and ventilation for safety and comfort of children. LPA observed a large size covered aquarium. LPA observed a glass door covered fireplace unit in the home. Off limit areas inside the home: three bedrooms, and attached garage. Off limit areas outside the home: right side of backyard that is gated and where storage shed is located. The Licensee has a pet dog (German shepherd mix) that is vaccinated and kept away from children. LPA observed a fenced backyard. LPA observed no bodies of water.

LPA observed a fully charged 3A40BC fire extinguisher and working smoke/carbon monoxide detectors. The Licensee states that there are no weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. LPA observed any poisons are locked in the attached garage inaccessible to the day care children.

A review of staff records on 08/19/21 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the
REPORT CONTINUED ON FOLLOWING PAGE #3 - REPORT DATED 08/19/2021):

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: SELBO, KRISTINE	FACILITY NUMBER: 434405879
	VISIT DATE: 08/19/2021

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

children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time without a fully qualified adult present. The Licensee states that she does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA conducted an exit interview with Licensee and she agreed to have the following item/s submitted to LPA Cruz by Thursday, 08/26/21.
1. Copy of MMR and TDAP immunization records for adult assistant, Marleen Capps.

No deficiencies issued during today's inspection.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3