<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422944
Report Date: 11/15/2023
Date Signed: 11/15/2023 01:29:16 PM


Document Has Been Signed on 11/15/2023 01:29 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:AGARWAL, SHRUTIFACILITY NUMBER:
013422944
ADMINISTRATOR:SHRUTI AGARWALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(518) 836-8473
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:14CENSUS: 5DATE:
11/15/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Shruti AgarwalTIME COMPLETED:
01:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On November 15, 2023, Licensing Program Analyst (LPA) Simerjit Kaur arrived at the facility to conduct UNANNOUNCED RANDOM REQUIRED SITE INSPECTION. LPA met with licensee Shruti Agarwal. There were 5 children present during the inspection. Present during the inspection were licensee's fingerprint cleared assistants Maryam Asas 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 1 school age children (1 eleven years old). Hours of operation for child care are Monday through Friday, 7:00am to 5:00pm. The facility is a two 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 5 children (3 infant age and 2 preschool age), and assistants Maryam Asas and Shila Asas.



ON LIMIT AREAS (accessible to children in care): Main House family room, half bathroom, Additional Dewelling Unit (ADU), which is the main day care area and consists of kitchen, 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. 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): main house: converted garage, second floor, and shed in the backyard. OFF Limit areas are inaccessible by closed and/or locked doors and visual supervision. Licensee is advised to contact the Department, so that an inspection can be completed prior to changing an OFF Limit area to ON Limit. Licensee was reminded that any structural changes or additions to the home must be reported to Community Care Licensing.
Continued on LIC 809C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Simerjit KaurTELEPHONE: (510) 622-2632
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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 3


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: AGARWAL, SHRUTI
FACILITY NUMBER: 013422944
VISIT DATE: 11/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
EMERGENCY PREPAREDNESS/SAFETY: Facility has a fully charged 3A40BC 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 6/28/2023 and meets six month guidelines. Licensees uses highchairs and tables for eating.

STAFF/CHILDREN RECORDS REVIEW: Licensee and all adults living and/or working in the home have proper criminal background clearances. assistants Maryam Asas and Shila Asas 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 and log for up to 24 months old children. 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.

Licensee was reminded that California law requires Licensees to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department within 24 hours by phone. Within seven (7) days from the incident, Licensee’s must submit the Unusual Incident/Injury form (LIC 624B) to the Department.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.
See 809C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Simerjit KaurTELEPHONE: (510) 622-2632
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: AGARWAL, SHRUTI
FACILITY NUMBER: 013422944
VISIT DATE: 11/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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-andresources/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 informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
During the exit interview, the Shruti Agarwal, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

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: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3