430751061-3-11-2025-07-CC-MKAR-DENM3U-20250311091544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430751061
Report Date: 03/07/2025
Date Signed: 03/11/2025 09:15:55 AM

Document Has Been Signed on 03/11/2025 09:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	CLOUTIER, ARLENE		FACILITY NUMBER:	430751061
ADMINISTRATOR/ DIRECTOR:	CLOUTIER, ARLENE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 245-1159
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 4	CENSUS: 3	DATE:	03/07/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:53 AM
MET WITH:	Arlene Clouter		TIME VISIT/ INSPECTION COMPLETED:	03:11 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	Licensing Program Analyst (LPA), Mandeep Kaur conducted an unannounced Annual/Random inspection. LPA met with Licensee, Arlene Clouter and explained to her the nature of today's inspection. Also present in the home were licensee's assistant (S1) and three (3) children including one infant. All required posting materials were posted. The daycare is open Monday through Friday from 07:30 AM to 6:30 PM. There are no active waivers or exceptions for this facility. Licensee states that licensee is the only adult resides in the home. LPA toured the indoor and outdoor areas of the facility with Licensee. LPA obtained a copy of current children's roster. Fire/disaster drill was conducted on January 28, 2025. LPA observed a fully charged fire extinguisher, functioning smoke and carbon monoxide detectors. Licensee states that there are no weapons or firearms in the home. Off limit areas inside the home are: Master Bedroom and garage. LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. Off limit areas outside the home: shed area and AC Unit. LPA reviewed three (3) children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), sleep log, and Immunization Records. Licensee has liability insurance for the day care home. Continuation on next pages:

Belinda Devall	TELEPHONE: (408) 598-5501
Mandeep Kaur	TELEPHONE: 408-334-8320
	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CLOUTIER, ARLENE	FACILITY NUMBER: 430751061
	VISIT DATE: 03/07/2025

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

LPA reviewed assistant's file for the following records: Employee Rights (LIC 9052), Statement acknowledging Requirement to Report Child Abuse (LIC 9108), immunizations, TB test, and required training. Licensee has immunizations in measles, pertussis and flu. At least one person present has current Pediatric CPR/First Aid certifications with an expiration date of July 24, 2026. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff and Licensee, every 2 years.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at an additional resource. LPA also reminded Licensee of the importance of checking for recalled infant deviceshttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as 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 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 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 in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Continuation on next pages:

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Mandeep Kaur	TELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CLOUTIER, ARLENE	FACILITY NUMBER: 430751061
	VISIT DATE: 03/07/2025

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

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 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&R's) throughout California.

No citation was issued during today's inspection.

Exit interview conducted and report was reviewed with Licensee, Arlene Clouter.

During the exit interview, the Licensee, Arlene Clouter, confirmed that there are no Registered Sex
Offenders living in the facility and LPA completed the RSO profile in FAS.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Mandeep Kaur	TELEPHONE: 408-334-8320
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3