Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434402285
Report Date: 02/16/2018
Date Signed 02/16/2018 02:14:51 PM

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: 0DATE:
02/16/2018
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Theresa LindsethTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an unannounced three year required random inspection to the home today. LPA met with Theresa Lindseth, Licensee, and explained the nature of today's inspection to her. Days and hours of operation are Tuesday to Friday from 8:30 AM to 3:00 PM during the school year and on Summer from 9:00 AM to 12:00 PM, Monday to Thursday. The adults that reside in the home are the Licensee, her two adult sons Alan and Ryan and her spouse Todd. There were not children in care during today's inspection. Licensee's certifications for CPR and First Aid card is current an will expire on 12/31/2018.
LPA toured the indoor and outdoor areas of the home during today's inspection. LPA reviewed the Child Care Facility Roster during today's inspection and it is current. Licensee has documented a fire drill during the last six months. Last fire drill was documented on 10/112017.
The Licensee has a working telephone (land line) in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Off limit areas inside are: 4 bedrooms, 1 bathroom, family room, laundry area and attached garage. LPA observed there are not stairs in the home. The home has a fireplace in the off limits family room and it has a glass screen. The off limits area outside the home: Left side yard, a locked screen room with access only from the back yard and a private garden in the right side yard. LPA observed the home has a swimming pool which has a cover. LPA observed the Licensee stand on the cover and it resisted a adult weight. LPA observed the home has a SPA which is in the off limits part of the back yard. The SPA is covered and locked. LPA observed the back yard is fenced. Licensee uses the back yard as playground whenever the weather is suitable.
LPA observed a fully charged 3A40BC fire extinguisher and working smoke detectors. LPA observed the home has at least one working carbon monoxide detector. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children. LPA discussed Incidental Medical Services (IMS) with the Licensee.
LPA explained to the Licensee of the immunization requirement for pertussis, measles, and flu vaccines for all Licensees and staff that work directly with the children (SB792). Licensee was able to present proof of having immunization for measles, pertussis and influenza.

Report dated 02/16/2018 continues in page 2.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2018
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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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: 02/16/2018
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Report dated 02/16/2018 continues from page 1.
A review of staff records on 02/14/2018 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 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, and a helper must be present whenever there are more than 8 children in care. Licensee understands that her license's capacity is reduced to only 8 if a helper is not present in the home. The Licensee states that she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time. Licensee uses redirection and communication with children as a form of discipline.
Department website: www.ccld.ca.gov provided to Licensee.
LPA discussed the requirements of AB 633 with the Licensee and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Licensee understands the requirements. LPA also discussed "zero tolerance" related regulations with the Licensee and advised her of the assessment of an immediate $500 civil penalty in addition to $100 per day civil penalty for any violation of a "zero tolerance" related regulation, and ongoing civil penalty of $100 per day continues until the violation(s) is corrected.
LPA prior to the conclusion of today's inspection advised the Licensee of the required "mandated reporter" training that all Licensees will be required to complete starting January 1, 2018. Licensee and her helper have already taken the mandated reporter training. LPA referred the Licensee to the Department website: www.ccld.ca.gov for additional information on the online training.

No deficiencies were cited during today's inspection. Appeal rights was printed and given to Licensee. Exit interview was conducted with Ms. Lindseth.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2018
LIC809 (FAS) - (06/04)
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