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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417457
Report Date: 04/19/2023
Date Signed: 04/19/2023 02:10:47 PM


Document Has Been Signed on 04/19/2023 02:10 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
OAKLAND SOUTH EAST, 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: DATE:
04/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Madhavi ShahTIME COMPLETED:
02:20 PM
NARRATIVE
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On April 19, 2023, Licensing Program Analyst (LPA) Simerjit Kaur arrived at the facility to conduct UNANNOUNCED RANDOM REQUIRED 1 YEAR SITE INSPECTION. LPA met with licensee Madhavi Shah. Upon arrival there were 12 children which consisted of 1 infant age, and 11 preschool age children. Present during the inspection was licensee's fingerprint cleared assistants Nachhtar Basra and Rajdeep Kaur. Also residing in the home is licensee's daughter Mahima Shah. Hours of operation for child care are Monday through Friday, 7:00am to 5:30pm. The facility is a one story house. The following was observed during today’s inspection:

CAPACITY: The facility operates as a Family Child Care Home (large), which may have a maximum capacity of twelve (12) to fourteen (14) children. At time of inspection, there were twelve children (one infant and eleven preschoolers), and assistant Nachhtar Basra and Rajdeep Kaur. The facility is in compliance with ratio and capacity limitations.


ON LIMIT AREAS (accessible to children in care): Kitchen, dining room, day care/living room, one bedroom on the right of hallway for napping, hallway bathroom, and backyard. LPA observed the facility to be clean and in good repair, with heating and ventilation for safety and comfort. There are ample age appropriate toys that are observed to be safe and in good condition. The backyard has a fence surrounding the perimeter of the yard.
OFF LIMIT AREAS (not accessible to children in care): Master bedroom and bathroom, office, garage, sides of the backyard. OFF Limit areas are inaccessible by closed and/or locked doors and visual supervision. Licensee is advised to contact Licensing Department, so that an inspection can be completed prior to changing an OFF Limit area to ON Limit.
Continued on LIC 809C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Simerjit KaurTELEPHONE: (510) 622-2632
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAH, MADHAVI
FACILITY NUMBER: 013417457
VISIT DATE: 04/19/2023
NARRATIVE
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There are no pools or any other bodies of water on the premises.

EMERGENCY PREPAREDNESS/SAFETY: Facility has a fully charged 3A40BC fire extinguisher. Smoke and carbon monoxide detectors were tested and found to be functioning. First aid supplies are available. A fire/disaster drill was last conducted on 4/10/2023 and meets the six month requirement. Facility has working telephone service. Per licensee, there are no firearms in the home. LPA reviewed Emergency Disaster Plan which licensee confirmed to still be current.

STAFF/CHILDREN RECORDS REVIEW: Licensee and all adults living and/or working in the home have proper criminal background clearances. Licensee has CPR/First Aid training. Licensee and staff are not in compliance with immunization law. Children's files were reviewed. A facility roster is maintained.


LICENSING POSTING (required): All REQUIRED forms should beposted and visible for public review: Facility license, Notification of Parents’ Rights, Earthquake Preparedness, Emergency Disaster Plan. 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.
Continued on LIC 809C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Simerjit KaurTELEPHONE: (510) 622-2632
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAH, MADHAVI
FACILITY NUMBER: 013417457
VISIT DATE: 04/19/2023
NARRATIVE
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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-and-resources/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 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.


See 809D. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Madhavi Shah.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Simerjit KaurTELEPHONE: (510) 622-2632
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/19/2023 02:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: SHAH, MADHAVI
FACILITY NUMBER: 013417457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as licensee does not have MMR vaccine, and assistant Rajdeep Kaur does not have TDAP, MMR, Flu vaccine, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Licensee shall submit proof of immunization for Rajdeep Kaur and licensee's MMR.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Simerjit KaurTELEPHONE: (510) 622-2632
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 04/19/2023 02:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: SHAH, MADHAVI
FACILITY NUMBER: 013417457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)

The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as there was unlocked cabinet with cleaning compounds under the sink in the on limit bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2023
Plan of Correction
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Licensee shall submit pictures of locked cabinet or can remove all the cleaning compounds by 4/20/23.
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adulit in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as licensee's assistant Rajdeep Kaur does not have proof of TB test, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Licensee shall proof of current Rajdeep Kaur's TB test by 5/3/23.
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: Simerjit KaurTELEPHONE: (510) 622-2632
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
LIC809 (FAS) - (06/04)
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