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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620834
Report Date: 08/04/2023
Date Signed: 08/04/2023 12:15:07 PM


Document Has Been Signed on 08/04/2023 12:15 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:RAI, SUSHMA KUMARIFACILITY NUMBER:
393620834
ADMINISTRATOR:RAI, SUSHMA KUMARIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 666-3021
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY:14CENSUS: 4DATE:
08/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Sushma Kumari RaiTIME COMPLETED:
12:15 PM
NARRATIVE
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On August 4, 2023, Licensing Program Analyst (LPA) Stacey Williams met with Licensee, Sushma Kuamari Rai for an unannounced annual inspection. LPA observed 4 children, (pre-school aged) supervised by Licensee and her Assistant. Licensee stated there are not any new residents in the home.

All individuals subject to criminal record review have obtained clearance.

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 toured areas of the home accessible to the children. The off-limit areas of the home were inaccessible (laundry room and entire upstairs). LPA did not observe any standing bodies of water during today’s inspection.

LPA observed the following licensing postings: family childcare license, a Parents' Rights Poster, facility sketch, and the Emergency Disaster Plan.

LPA conducted file reviews during today’s inspection. LPA observed current CPR/First Aid certificate which expires 9/2024. LPA observed that licensee does not have current completion of AB1207 Mandated Reporter training. LPA provided Licensee with website: http://childcare.mandatedreporterca.com/ and reminded the licensee that the training must be completed once every two years. LPA observed records of immunizations for MMR, Pertussis, and influenza/ influenza declination. Licensee’s Assistant does not have a TB Clearance on file. LPA reviewed children's records for completeness, as well as the client roster.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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


Document Has Been Signed on 08/04/2023 12:15 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: RAI, SUSHMA KUMARI
FACILITY NUMBER: 393620834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based record review, the license did not comply with the section cited above in 1 out of 2 files that were reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2023
Plan of Correction
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Licensee shall ensure that she and all staff have the completed mandated reporter training on file. Mandated Reporter training is required to be completed every two years for Licensee and all staff working in the facility. Licensee shall submit copy of mandated reporter training certification to CCL by POC date- 9/4/23.
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
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 files that were reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Licensee shall submit proof of complete immunization records for her Assistant . Immunization record shall include TB clearance. Licensee shall submit immunization records to CCL by POC date- 9/4/23.
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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: RAI, SUSHMA KUMARI
FACILITY NUMBER: 393620834
VISIT DATE: 08/04/2023
NARRATIVE
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LPA observed that hazardous items: detergents, cleaning compounds, medication, sharp utensils, and other items that could pose a danger to children in care, are properly stored out of children's reach. LPA observed a fireplace that was properly screened. Stairs were properly barricaded. LPA observed a working telephone in the home. Licensee stated that there are no weapons in the home. Licensee stated there are no pets in the home.

LPA observed a fire extinguisher which licensee stated was serviced or change within the past year. Carbon monoxide and smoke detectors were tested and observed to be functional.

LPA observed fire drills documented on a calendar, indicating that the licensee is conducting disaster drills at least once every 6 months.

Equipment and furnishings in areas where children are active appeared to be safe and in working order. Appropriate nap equipment for infants was observed. Licensee stated she does not provide care to infants.


LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage: 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.

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/.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: RAI, SUSHMA KUMARI
FACILITY NUMBER: 393620834
VISIT DATE: 08/04/2023
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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 Licensee, Sushma Kumar Rai, 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.


Deficiencies were observed during today’s inspection and are cited on the following page of this report ,LIC 809D.

LPA reviewed report with the Licensee, Sushma Kumari Rai and provided copies of the report along with Appeal Rights. A notice of site visit was provided and posted by LPA Williams and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.



SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4