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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417457
Report Date: 02/21/2020
Date Signed: 02/21/2020 03:20:53 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:
02/21/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Madhavi ShahTIME COMPLETED:
04:00 PM
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On 02/21/20, Licensing Program Analyst Leslie Ibo met with licensee Madhavi Shah for an UNANNOUNCED POC INSPECTION. Present for this visit was licensees fingerprint clear assistant Nachter Basra, 3 infants, and 7 preschool age children 3 school aged. The home was toured to conduct health and safety.

The licensee is in ratio today. A POC letter was issued for the citation cited on 02/13/2020. 13 children's records were reviewed with Lic.9224 in file.

There are no deficiencies cited during today's inspection. 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: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: (510) 622-2646
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2020
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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