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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422944
Report Date: 10/06/2022
Date Signed: 10/06/2022 02:16:41 PM


Document Has Been Signed on 10/06/2022 02:16 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:AGARWAL, SHRUTIFACILITY NUMBER:
013422944
ADMINISTRATOR:SHRUTI AGARWALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(518) 836-8473
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:14CENSUS: 8DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Shruti AgarwalTIME COMPLETED:
12:25 PM
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On 10/6/2022, Licensing Program Analyst (LPA) Simerjit Kaur arrived at the facility to conduct UNANNOUNCED RANDOM REQUIRED 1 YEAR SITE INSPECTION. LPA met with licensee Shruti Agarwal. Upon initial arrival there were 8 children. Present during the inspection were licensee's fingerprint cleared assistants Asma Seaboui and Shila Asas. Also, residing in the home are licensee's husband Rahul Agarwal, mother-in-law Shikha Agarwal, father-in-law Radha Agarwal and licensee's 2 school age children (1 nine year old and 1 seventeen years old). Hours of operation for child care are Monday through Friday, 7:00am to 5:00pm. The facility is a two story house and second floor is barricade with gate. 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 8 children (4 infant age and 4 preschool age), and assistants Asma Seaboui and Shila Asas.



ON LIMIT AREAS (accessible to children in care): Main House Living room, family room, kitchen, half bathroom, backyard, day care room in the backyard, half bathroom in day care room. 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. 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 (not accessible to children in care): second floor, shed in the backyard and garage. 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: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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: AGARWAL, SHRUTI
FACILITY NUMBER: 013422944
VISIT DATE: 10/06/2022
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EMERGENCY PREPAREDNESS/SAFETY: Facility has a fully charged 2A10BC fire extinguisher. Smoke and carbon monoxide detectors were tested and found to be functioning. Facility has working telephone service. Per licensee, there are no firearms in the home. The fire/diaster drill was conducted on 8/9/2022 and meets six month guidelines.

STAFF/CHILDREN RECORDS REVIEW: Licensee and all adults living and/or working in the home have proper criminal background clearances. Assistants Lakshmi Nullaprdi, and Sonia Luhana have current CPR/First Aid training. Licensee and assistants have current mandated reporter training. Staff and children's files were reviewed. Licensee maintains an Infant Sleep Plan for infants up to 12 months old. A facility roster is maintained and a copy obtained.

LICENSING POSTING (required): All REQUIRED forms are posted 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.
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.

Continued on LIC 809C

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

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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: AGARWAL, SHRUTI
FACILITY NUMBER: 013422944
VISIT DATE: 10/06/2022
NARRATIVE
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EMERGENCY PREPAREDNESS/SAFETY: Facility has a fully charged 2A10BC fire extinguisher. Smoke and carbon monoxide detectors were tested and found to be functioning. Facility has working telephone service. Per licensee, there are no firearms in the home. The fire/diaster drill was conducted on 6/16/2022 and meets six month guidelines.

STAFF/CHILDREN RECORDS REVIEW: Licensee and all adults living and/or working in the home have proper criminal background clearances. Assistant Shila Asas and licensee have current CPR/First Aid training. Licensee and assistants have current mandated reporter training. Staff and children's files were reviewed. Licensee maintains an Infant Sleep Plan for infants up to 12 months old. A facility roster is maintained and a copy obtained.

LICENSING POSTING (required): All REQUIRED forms are posted 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.
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.

Continued on LIC 809C

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

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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: AGARWAL, SHRUTI
FACILITY NUMBER: 013422944
VISIT DATE: 10/06/2022
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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.



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/process.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Shruti Agarwal.

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

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4