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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423375
Report Date: 02/18/2022
Date Signed: 02/18/2022 01:45:10 PM


Document Has Been Signed on 02/18/2022 01:45 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:GUPTA, MILPAFACILITY NUMBER:
013423375
ADMINISTRATOR:MILPA GUPTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 875-1872
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:14CENSUS: 0DATE:
02/18/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Milpa GuptaTIME COMPLETED:
02:00 PM
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On 2/18/2022 at 1:10pm Licensing Program Analyst Jaylena Miller conducted an announced case management visit to the facility for the purpose of re-activating the license and LPA met with licensee Milpa Gupta. LPA conducted a health and safety inspection of the home. LPA observed fully charged 2A-10-BC fire extinguisher, working carbon monoxide detector and working smoke detector. Per licensee, there are no pets, firearms or weapons at the facility. LPA observed the facility to be neat and clean with sufficient toys, furnishings and equipment for children.

The on limit areas are the living room, kitchen with dining area, family room which is used as the main daycare area, the 1/2 bathroom and the backyard which is fully fenced will be used as the outdoor play area.

The off limits will be the entire upstairs area, garage and guest bedroom on the first floor and will be made inaccessible by locked doors, safety gates and 100% visual supervision.

Licensee has current CPR/1st Aid which expired 11/2022, and Mandated Reporter training on 8/2/2020.

As of today, 2/18/2022 the license is now active and current.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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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