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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417457
Report Date: 02/13/2020
Date Signed: 02/13/2020 02:33:13 PM

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: 13DATE:
02/13/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Madhavi ShahTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Leslie Ibo arrived at the facility for an unannounced Annual/Random Inspection and met with licensee Madhavi Shah. Present for this inspection was finger print cleared assistant Nachhtar Basra, 5 infants, 8 preschool aged children. At 12:30 PM C1 was picked up by a parent,
At 12:35PM 1 preschool aged child was picked up by grand parent, this child was licensee's own grandchild. At 1:40PM 2 school aged (c5 & c6) children was dropped off to the facility, at 2:09PM school aged child was dropped off at the facility, the total number of children was 14 ( 4 infants, 7 preschool aged and 3 school aged children) . Also residing at home are the licensee’s finger print cleared husband Anand Shah and 1 minor child. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 7:00AM – 6:00PM.

ON LIMITS: play room/dining room, kitchen, day care room, bedroom located at the end of hallway, bathroom located left side of the hallway, backyard

OFF LIMITS: 2 bedrooms located in the hallway, 1 bathroom located in off limit of the bedroom and garage which will be inaccessible by closed and/or locked doors and visual supervision , front patio
ISOLATION: dining room

The home is single story. There were ample age appropriate toys that were observed to be safe and in good condition. Toxins, medicines, and hazardous items were inaccessible during today's inspection. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone, and first aid kit.
***Continued on LIC809C…
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: (510) 622-2646
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2020
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAH, MADHAVI
FACILITY NUMBER: 013417457
VISIT DATE: 02/13/2020
NARRATIVE
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There are no pools, hot tubs or any other bodies of water. The home has a fireplace that is blocked, and licensee stated it is not being used. Per licensee, there are no firearms in the home. All required licensing documents are posted and visible for public review.

Children's files were reviewed found to be complete per licensing regulation. The facility roster was reviewed, and a copy was obtained. The licensee's Pediatric CPR/First Aid certificate is current with an expiration date of 6/30/2020, licensee’s assistant has a current CPR/First Aid certificate with an expiration date of 5/11/2021. Licensee has current mandated reporter training that was done 3/20/2019 and has a proof of required immunization's. Licensee has completed disaster drill with the last drill conducted 2/3/2020, copy was obtained for documentation purposes. Safe Sleep practices were discussed, and new car seat laws were provided. Licensee was advised to conduct and document fire and disaster drills for the new day care children at least once every six months. Licensee was reminded that exersaucers, baby walkers, bouncers, jumpers, and similar items are not allowed, and that smoking is prohibited in the home during day care hours. Licensee transports children. Licensee was reminded that children are never to be left in a parked vehicle.
Licensee and LPA discussed about the document needed for new staff for her day care facility.

A review of staff records indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearance or exemptions. Licensee was reminded that anyone working, residing or frequently visiting the home must be fingerprint cleared prior to being in the presence of children, or an immediate civil penalty can be assessed. Licensee is aware that any authorized employee of the Department may enter and inspect the home with or without advance notice.
***Continued on LIC809C…
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: (510) 622-2646
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SHAH, MADHAVI
FACILITY NUMBER: 013417457
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2020
Section Cited

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102416.5 Staffing Ratio and Capacity
The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.
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This requirement is not met as evidenced by: Based on observation and physical census the facility , At 12:17PM LPA observed the facility was out of ratio with 5 (infants) and 8 (preschool age) children in care which poses an immediate health and safety risk to children in care.
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LIC9224 was provided to licensee, a copy of will be provided to all the parents of the day care children and a copy of LIC9224 will be provided to new enrollees (2/13/2020 - 2/13/2021). Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: (510) 622-2646
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAH, MADHAVI
FACILITY NUMBER: 013417457
VISIT DATE: 02/13/2020
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Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to also email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list.

Individual Medical Services (IMS) policy was discussed. When any changes to the IMS plan is made, an updated 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: http://www.ada.gov/childqanda.htm.”

See LIC809D for deficiencies cited today.



Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

This report shall remain on file for 3 years. A Notice of Site visit was posted at time of inspection and must remain posted for 30 days.
Exit interview conducted with licensee Madhavi Shah. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: (510) 622-2646
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4