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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422828
Report Date: 05/17/2023
Date Signed: 05/17/2023 12:08:18 PM


Document Has Been Signed on 05/17/2023 12:08 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:PULUSU, VISALAKSHMIFACILITY NUMBER:
013422828
ADMINISTRATOR:PULUSU, VISALAKSHMIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 378-3866
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:14CENSUS: 10DATE:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Visalakshmi PulusuTIME COMPLETED:
12:20 PM
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On May 17, 2023 at approximately 8:40am Licensing Program Analyst (LPA) Haderer arrived and met with the licensee Visalakshmi Pulusu for the purpose of conducting an unannounced 1-year annual inspection for Health and Safety compliance. Present in the home today was the licensee, two fingerprint and TB tested assistants and 10 children in care (3 infants; 5 two-years old; 1 three-years old; 1 four-years old), the facility is in ratio today. Hours of operation are Monday -Friday 8:30 to 6:00pm.

The facility is a single-story home with 4 bedrooms; 3 bathrooms; living room; eat-in dining room in the kitchen; kitchen; attached 1-car garage; front, back and side yards. There is a free-standing 2-bedroom 2-bathroom mother-in-law apartment in the back yard of the property. There is a screened fireplace in the living room blocked by a large piece of furniture. The home has heating and ventilation for safety and comfort. Per the licensee, the ISOLATION AREA will be in the emergency on-limits bedroom on the left side of the hall away from the other children in care. All required postings are present.

ON LIMIT AREAS: Living room; kitchen; eat-in dining room in the kitchen, bedroom on the left side of the house bathroom; bedroom (emergency bedroom) on right side of the house bedroom; the house bathroom on the left side of the hall; backyard covered concrete patio area. Licensee was reminded that other than wipes or things used for the children in the on limits children’s bathroom, they need to be empty of most all items (or locked up) such as cleaning products. All cabinets in the kitchen had childproof locks to prevent access by children.



OFF LIMIT AREAS: Bedroom on the right side of the hall (including attached bathroom); master bedroom and bath at the end of the hall in the rear of the home; attached 1-car garage; and western side of the backyard with a free-standing 2-bedroom mother-in-law apartment unit and the artificial grass area in from of the unit. The off-limit areas will be inaccessible by child gates, closed and/or locked doors and adult supervision.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: PULUSU, VISALAKSHMI
FACILITY NUMBER: 013422828
VISIT DATE: 05/17/2023
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The home has a fully charged 3A40BC fire extinguisher mounted in the kitchen by the front door, combined smoke and carbon monoxide detectors (tested and working) and a working telephone. Fire drills are conducted at least once every 6 months, the last drill was completed January 23, 2023.

Licensee has ample age-appropriate toys and learning materials inside and outside the home. The outdoor play area is free from defects and dangerous conditions. Per licensee, there are no firearms in the home. Drop-down cribs are not allowed at the day-care facility. Toxins, medicines, and hazardous items were inaccessible during today's inspection.

Children’s files were reviewed, a copy of the roster was taken by the LPA for the office file. Files were organized, one child’s file was missing the signed Consent for Medical Treatment form LIC627, - see LIC809D for deficiency. The licensee cares for children older than 12 months and under 24 months but has not been maintaining the sleep logs to monitor and document 15 minute checks on their sleeping. LPA reviewed the safe sleep regulation and provided sample logs to be maintained for all infant children up to 24 months in age - see LIC809D for deficiency. The licensee owns the property and does not carry liability insurance. All children’s files contained the LIC282 Notice of no insurance and all were signed and dated.

Licensee has all required immunizations. CPR/1st Aid was available for licensee and expire on 12/11/2023. Mandated Reporter was completed on 7/7/2021. Helpers’ immunization records were verified in compliance with childcare regulations; and helpers Mandated Reporter certifications were checked and not expired. Licensee was reminded that CPR/1st Aide and Mandated Reporter is to be renewed every two years.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a 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
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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: PULUSU, VISALAKSHMI
FACILITY NUMBER: 013422828
VISIT DATE: 05/17/2023
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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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

The following two deficiencies were observed during today's inspection:

· LIC627 form Consent for Emergency Medical Treatment was present and filled out but not signed by parent


· Children are viewed while napping but Sleep Logs for infants up to age 24 were not maintained

See 809D 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.

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

Exit interview conducted and report was reviewed with the licensee Visalakshmi Pulusu.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/17/2023 12:08 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: PULUSU, VISALAKSHMI
FACILITY NUMBER: 013422828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that licensee and aid supervise the children at nap time but were not keeping the written sleep logs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2023
Plan of Correction
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LPA printed sleep logs examples for the licensee. Going forward, licensee will ensure to records sleep logs for all infants up to age 24 months and store them for three years.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one child's Consent for Emergency Medical Treatment form LIC627 was not signed by the parent which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2023
Plan of Correction
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Licensee will obtain parent's signature on the LIC627 form and ensure all documents in children's files are complete and signed, dated by parents.
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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4