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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407434
Report Date: 05/10/2019
Date Signed: 05/10/2019 03:36:31 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MUMMIDIVARAPU, BHAVANIFACILITY NUMBER:
434407434
ADMINISTRATOR:MUMMIDIVARAPU, BHAVANIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 725-8925
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:14CENSUS: 11DATE:
05/10/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Bhavani MummidivarapuTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA), Marilou Monico, made an annual random inspection. Present in the home were licensee, licensee's 16-year-old daughter, two adult helpers, and 11 daycare children including two infants and nine preschool age. The daycare is open Monday thru Friday from 8:30 AM to 6:00 PM. Licensee, her husband, her father-in-law are the adults residing in the home. Licensee and her helpers have current CPR/First Aid certifications with an expiration date of September 30, 2020.

The indoor and outdoor areas were inspected. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean and safe for the daycare children. There is a fully charged 3A40BC fire extinguisher, working smoke and carbon monoxide detector, barricaded fireplace, and no bodies of water. Off limit areas in the home: all 4 bedrooms, 3 bathrooms, and living room. Off limit areas outside: detached garage, and carport area. Cleaning compounds, medications, sharp objects, and other similar items are stored inaccessible to children. Per licensee, there are no weapons in the home. Six children's files and three helper's files were reviewed. Licensee and her helpers have immunizations in measles, pertussis, and influenza. LPA reviewed children's roster and fire drill log. LPA obtained copies of children's roster.

LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years. AB 633 was discussed with Licensee. Licensing forms, Title 22 regulations, can be obtained through the internet at ww.ccld.ca.gov. Mandated Reporter Training can be accessed at www.mandatedreporterca.com. Licensee and her helpers have completed the Mandated Reporter Training online. LPA discussed and provided licensee with lead information sheets and advised her to provide copy to parents.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 05/10/2019):
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MUMMIDIVARAPU, BHAVANI
FACILITY NUMBER: 434407434
VISIT DATE: 05/10/2019
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/10/2019):

A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

As a result of this inspection, there were no deficiencies cited.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
LIC809 (FAS) - (06/04)
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