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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214200082
Report Date: 08/19/2025
Date Signed: 08/19/2025 01:05:07 PM

Document Has Been Signed on 08/19/2025 01:05 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:GOCHBERG, JODIFACILITY NUMBER:
214200082
ADMINISTRATOR/
DIRECTOR:		JODI GOCHBERGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 250-8465
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
08/19/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Jodi GochbergTIME VISIT/
INSPECTION COMPLETED:
01:27 PM
NARRATIVE
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On 8/19/2025, Licensing Program Analyst (LPA) Naves conducted an unannounced annual visit to the Family Childcare Home (FCCH) listed above. LPA met with the Licensee, Jodi Gochberg, and explained the purpose of the visit.
6 children (3 infants and three pre-k) and 2 additional helper adults were present during the visit. The 3 adults present have all received criminal record clearance from the department. The licensees hold a large license and is within capacity limits and ratios.

The licensee rents the home. The hours of operation are Monday through Thursday from 7:30 am to 5:30 pm and Fridays 7:30- 5:00pm.

LPA observed that all required documents, such as the facility license, the Notification of Parental Rights, and the Earthquake Preparedness Checklist, were displayed in a prominent, publicly accessible location.
The most recent emergency disaster drill was conducted on 3/3/2025, and the LPA observed that it was properly documented. LPA reviewed the emergency disaster drill log and found that they were conducted at least every six months.

Daycare Areas: Living Room, Playroom, Bedroom #1, Bedroom #2, Bathroom #1, Kitchen, and Yard Area.
Off-limit Areas: Bathroom #2. The licensee understands that off-limits areas may not be used for childcare during business hours.
cont pg 2 >>>>
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2025
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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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)
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Document Has Been Signed on 08/19/2025 01:05 PM - It Cannot Be Edited


Created By: Jaclyn Naves On 08/19/2025 at 12:28 PM
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: GOCHBERG, JODI
FACILITY NUMBER: 214200082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in not having sleep logs documented. Licensee was given a TV the year before for not doing logs, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Licensee will begin documenting 15 minute sleep checks for all infants under the age of 2 years old and educate staff on doing so as well daily. Licensee will send LPA proof by 9/19/25 after a months documentation.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review , the licensee did not comply with the section cited above in not having a valid Pediatric First Aid/CPR certification, one on file expired 1/2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Licensee will sign up for a Pediatric First Aid/CPR class and send LPA proof through email once complete by due date of 9/19/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Jaclyn Naves
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GOCHBERG, JODI
FACILITY NUMBER: 214200082
VISIT DATE: 08/19/2025
NARRATIVE
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LPA conducted inspections of the indoor and outdoor daycare areas to identify health and safety hazards. Several fire extinguishers, a first aid kit, a carbon monoxide and smoke detector are present in the home. LPA found the home's interior to be clean and orderly, with proper heating and ventilation for safety and comfort. Disinfectants, cleaning solutions, poisons, and other hazardous items were stored in areas inaccessible to children with child safety locks. The bathroom was found to be clean and fully operational. LPA found that latch for under the bathroom sink is not functioning properly licensee will be replacing. The toilet and handwashing facility were well-kept, safe, and clean. The bathroom is equipped with appropriate toileting equipment and appropriate sanitation products.

LPA observed that the daycare areas had age-appropriate toys, furniture, and educational materials. Electrical outlets were properly covered with child safety covers. According to the licensee, no firearms or weapons are on the premises.

The licensee does not currently provide food service for the children. The children's families provide their lunches. LPA observed the children’s lunches inside the refrigerator. LPA reminded the licensee that the children's lunches must have the children 's names on them.

The backyard is enclosed by a fence and equipped with outdoor play equipment that is in good condition with age-appropriate toys. Currently the licensee is not utilizing the back yard area as the gate is not properly working. Licensee stated she instead does outside play time by taking children on walks. LPA did not observe any pools, spas, or bodies of water on site.

The facility's children sleep on mats and in playpens. The playpens were free of loose articles and materials. According to the licensee, the sheets and blankets that are available for the children are washed once or twice a week or as needed.
cont pg 3 >>>>
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: GOCHBERG, JODI
FACILITY NUMBER: 214200082
VISIT DATE: 08/19/2025
NARRATIVE
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LPA reviewed 6 children’s files and confirmed 4 have complete files that include their emergency contact and medical information. 1 child was missing form LIC 995a, and one child was missing their immunization records and Lic 627 Consent for Emergency Medical Treatment. LPA provided and reminded the licensee the Entrance Checklist, LIC 126, to ensure that all required licensing forms are in the child’s file. According to the licensee, she visually checks the children under the age of two when they’re sleeping, however licensee was unable to provide sleep log records during today’s visit. LPA reminded the licensee that children under the age of two must use sleep logs that document their sleep every 15 minutes. LPA explained how to properly log the 15-minute sleep checks.

LPA reviewed the licensee’s files and confirmed that all required forms were present. LPA found that the licensee does not possesses a current Pediatric First Aid/CPR certification. Licensees staff member does have a current Pediatric First Aid/CPR certification. LPA reminded licensee it is a requirement for her to possess a current valid Pediatric First Aid/CPR certificate. Licensee stated she will complete right away. LPA requested a copy be submitted to LPA as soon as completed. LPA reminded licensee it needs to be renewed every 2 years. The licensee has current Mandated Reporter Training that expires 9/2026.

LPA reviewed the 80/20 absence expectation with licensee.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
cont pg 4 >>>>
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: GOCHBERG, JODI
FACILITY NUMBER: 214200082
VISIT DATE: 08/19/2025
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at

https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.


cont pg 5 >>>>
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: GOCHBERG, JODI
FACILITY NUMBER: 214200082
VISIT DATE: 08/19/2025
NARRATIVE
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page 5

The facility was issued a technical violation for the bathroom latch a deficiency was cited for not having a current Pediatric First Aid/CPR certification and for not having a log of the fifteen-minute sleep checks for children under the age of two.

Licensee was reminded her annual licensing fees are due at the end of the month.

Please refer to LIC 809D for today’s citations.

The licensee, Jodi Gochberg, was given a copy of today's report and the facility’s appeal rights.

A Notice of Site Visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Jodi Gochberg.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jaclyn Naves
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
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