Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434402285
Report Date: 04/16/2015 12:00:00 AM
Date Signed 04/16/2015 09:54:49 AM

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:LINDSETH, THERESAFACILITY NUMBER:
434402285
ADMINISTRATOR:LINDSETH, THERESAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 848-5051
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 11DATE:
04/16/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Theresa LindsethTIME COMPLETED:
10:00 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
LPA Barbara Walker met with provider for an unannounced random visit. Toured the home and yard, and reviewed day-care forms with provider. Off-limits areas includes all bedrooms, laundry room, dog kennel, and garage. Present is provider, assistant, adult son, and 11 preschoolers. Provider reviewed fingerprint clearances printout and confirmed that all adults living or working in the home are listed. Provider owns home. Provider has Allstate liability insurance. Day-care operates 8:30 am- 11:30 am, Tues-Fri during the school year and will be operation different days & hours during the summer. Provider, spouse and two adult sons reside in the home. Provider CPR/First Aid expire 1/2017.

Provider conducts fire/disaster drills at least every 6 months, and documents them. The provider has a working telephone (landline) in the home. Provider has sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children.

Provider has the appropriate fire extinguisher. Provider has a working smoke detector, and backyard is enclosed. Pool is covered with cover, which the provider walked on, Jacuzzi is covered and locked. Provider stated that there are no weapons in the home. All detergents and cleaning compounds are inaccessible to children. Medications, and other similar items are stored inaccessible to children. All poisons are inaccessible to children. Provider has one dog, two cats, and 2 guinea pigs.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Barbara WalkerTELEPHONE: (408) 334-8553
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2015
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 2


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: LINDSETH, THERESA
FACILITY NUMBER: 434402285
VISIT DATE: 04/16/2015
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
A review of staff records on April 15, 2015, 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 reminded provider 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 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 provider. 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 provider understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Provider understands that if she has an assistant, they must have fingerprint clearance, current CPR & 1st Aid, and TB tested before providing care and supervision. The provider states that she does not transport children. The provider understands that children cannot be left in parked vehicles unattended at any time.

A Family Child Care Home packet with updated Licensing forms was reviewed and provided. Department website: www.ccld.ca.gov.

LPA discussed the requirements of AB 633 with the provider and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and provider understand the requirements. LPA also discussed "zero tolerance" related regulations with the provider and advised her of the assessment of an immediate $150 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $150 per day continues until the violation(s) is corrected.

No deficiencies cited.

NOTICE OF SITE VISIT ISSUED, POST AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Barbara WalkerTELEPHONE: (408) 334-8553
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2015
LIC809 (FAS) - (06/04)
Page: 2 of 2