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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417457
Report Date: 03/10/2023
Date Signed: 03/10/2023 11:02:57 AM


Document Has Been Signed on 03/10/2023 11:02 AM - It Cannot Be Edited

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: 11DATE:
03/10/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Madhavi ShahTIME COMPLETED:
11:10 AM
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On March 10, 2023, Licensing Program Analyst (LPA) Simerjit Kaur met with licensee Madhavi Shah for the Case Management Inspection to revise off-limits into on-limits areas of the home. Present for today’s inspection was licensee, her fingerprint and associated assistant Rajdeep Kaur. Also, present during the inspection, Therapist Mellissa Thatcher, 2 infant age children, and 9 preschool age children. Hours of operation for child care are Monday through Friday, 7:00am to 5:30pm.

Licensee requested to convert previously off-limit areas in her home into on-limits areas.

NEW ON-LIMIT AREAS: Kitchen, dining room, day care/living room, one bedroom on the right of hallway for napping, hallway bathroom, and backyard. New on-limits areas were inspected for health and safety. LPA observed the facility to be clean and in good repair, with heating and ventilation for safety and comfort. The backyard has a fence surrounding the perimeter of the yard. LPA did not observe any dangerous conditions, nor any hazardous or toxic items accessible to children in the ON Limit areas of the facility today.



OFF LIMIT AREAS: Master bedroom and bathroom, office, garage, sides of the backyard. OFF Limit areas are inaccessible by closed and/or locked doors and visual supervision.

Exit interview was conducted and report was reviewed with the Licensee Madhavi Shah . Notice of Site Visit was issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Simerjit KaurTELEPHONE: (510) 622-2632
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
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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