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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417457
Report Date: 05/15/2019
Date Signed: 05/15/2019 10:11:48 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SHAH, MADHAVIFACILITY NUMBER:
013417457
ADMINISTRATOR:SHAH, MADHAVIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 487-3093
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:14CENSUS: 10DATE:
05/15/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Madhavi ShahTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Simerjit Kaur conducted an Unannounced Case Management Inspection. Present during the inspection was the licensee, fingerprint clear and associated assistant Nachhtar Basra and 2 infant children and 8 preschool age children in care.

An annual random inspection was conducted on 03/20/19 and backyard was placed off-limits area. Today 05/15/19, LPA Kaur conducted inspection to ensure the backyard is securely fenced. The left side of the backyard is off limit. The backyard was observed to be safe for children during today's inspection. The backyard is now on limits. The ON LIMIT AREAS are the play room/dining room, kitchen, day care room, bedroom located at the end of hallway, bathroom located left side of the hallway and backyard. The OFF LIMIT AREAS are 2 bedrooms located in the hallway, 1 bathroom located in on limit bedroom, left side of the backyard and garage which will be inaccessible by closed and/or locked doors and visual supervision. Safe Sleep Regulation was provided and discussed.

No deficiencies cited today. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Simerjit KaurTELEPHONE: (510) 292-7241
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019
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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