073407162-3-7-2022-52-CC-MPRE-CCAUDF-20220307142929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073407162
Report Date: 03/07/2022
Date Signed: 03/07/2022 02:29:46 PM

Document Has Been Signed on 03/07/2022 02:29 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	SRIVASTAVA, SHALINI		FACILITY NUMBER:	073407162
ADMINISTRATOR:	SRIVASTAVA, SHALINI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 556-9265
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94582
CAPACITY:	14	CENSUS: 12	DATE:	03/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Shalini Srivastava		TIME COMPLETED:	02:20 PM

NARRATIVE

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On 3/7/2022 at 11:40am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee’s Assistant Sumi Pothen for an Unannounced Annual Inspection. Present during the inspection were two (2) Assistants, S. Pothen, R. Pinnani and twelve (12) preschool age children. Licensee returned home at 12:00pm and continued the inspection. Licensee's home was toured for a health and safety inspection. The facility operates 8:30am – 6:00pm, Monday - Friday.

The main home is a two story home owned by the Licensee. The Licensee only uses the single-story in-law unit that is located on the property for childcare. The in-law unit is a detached structure with one (1) bathroom, one (1) opened half bathroom, kitchen, playroom, nap room, and a backyard. The entire main house is “off-limits.” Licensee provided an updated form 999A Facility Sketch during inspection.

ON LIMITS AREA: Entire in-law unit and Backyard

OFF LIMITS AREA: Entire main house
ISOLATION AREA: Half bath

The inside of the unit is observed to be neat, clean with ample age appropriate materials for the children that are safe. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there no firearms on the property and one (1) dog in the main home.

The unit has one (1) fully charged 3A40BC fire extinguisher in the nap room next to the entry way. There is one (1) one working smoke/carbon monoxide combination detector in the nap room and one working smoke detector in the playroom. The unit is equipped with two heat/air conditioners that are placed just under the ceiling above the doorway in both rooms.

Continued on LIC809-C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

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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Document Has Been Signed on 03/07/2022 02:29 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRIVASTAVA, SHALINI	FACILITY NUMBER: 073407162
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2022
	Plan of Correction
1 2 3 4	Licensee will ensure A1, A2 and V1 provide the proper ducumentation for proof of all missing immunizations. Licensee will send LPA proof of correction by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRIVASTAVA, SHALINI	FACILITY NUMBER: 073407162
	VISIT DATE: 03/07/2022

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The Licensee’s Health and Safety training has been completed. CPR and First Aid training is complete with an expiration date of 9/18/2023. Licensee’s Mandated Reporter is complete and expires 3/18/2022. All required forms are posted and visible for public view by the entry way. Fire and disaster drill log is complete. Last drill was logged is 2/12/2022. LPA obtained the children’s files, two (2) assistant files and (1) volunteer’s file and the facility roster. All children’s files and facility roster were complete. All staff files were incomplete. A1 was missing proof of immunization for MMr, Tdap and TB; A2 was missing proof of immunization for MMr, TB and flu vaccination and V1 was missing proof of TB test (see LIC809D). A2 was also missing a Mandated Reporter certificate, (See LIC9102TV).

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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.

Continued on LIC809-C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRIVASTAVA, SHALINI	FACILITY NUMBER: 073407162
	VISIT DATE: 03/07/2022

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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.

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.

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

Exit interview conducted and report was reviewed with Shalini Srivastava.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC809 (FAS) - (06/04)

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