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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408614
Report Date: 03/04/2020
Date Signed: 03/04/2020 01:09:59 PM

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:DEVI, SHANTIFACILITY NUMBER:
434408614
ADMINISTRATOR:DEVI, SHANTIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 887-3649
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:14CENSUS: 6DATE:
03/04/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Shanti DeviTIME COMPLETED:
01:30 PM
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On 03/04/2020, Licensing Program Analyst (LPA) Manel Estoesta, met with licensee Shanti Devi for an UNANNOUNCED Required 1 Year Inspection. Present for this visit were fingerprinted and criminal record cleared Licensees' daughter Geetam Das, Licensee's spouse Durga Lall, Assistant Providers Samjhan Puri and Vijeta Garg, 4 infants and 2 preschool children. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from Monday to Friday 08:30AM to 06:00PM.

The home is a one story home. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the hallway bathroom, living room, family room, a day care bedroom , dining room and backyard. The BACKYARD play area is completely fenced. The OFF-LIMIT AREAS are two bedrooms, master bedroom, master bath and the garage which will be inaccessible by closed and or locked doors and or a fence with visual supervision. The ISOLATION AREA will be the day care bedroom. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.

The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector and working telephone. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 09/14/2019. Licensee's daughter, Geetam Das, owns the house and facility does not carry liability insurance or a bond. Licensee maintain the signed the forms LIC 282 AFFIDAVIT REGARDING LIABILITY INSURANCE in the facility file.

See LIC 809-C for continuation



SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
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
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: DEVI, SHANTI
FACILITY NUMBER: 434408614
VISIT DATE: 03/04/2020
NARRATIVE
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The licensee CPR and First Aid certificate expires on May of 2020. The licensee completed the mandated reporter training 05/23/2018. Licensees have records of Measles and Pertussis immunization, Influenza vaccination and TB clearance. LPA reminded Licensee that only the Influenza vaccination can be decline with a written declination.

Facility roster of children was reviewed, and a copy was obtained. Children’s files were reviewed, which included records of receipt for Parents' Rights Notice, Identification and Emergency Information, Consent for Emergency Medical Treatment form, and Immunization. The licensee is in ratio today.

Licensee stated that she does NOT transport children at this time, and she has a current and valid Driver License. Licensee understands that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children in care shall be maintained in safe operating conditions, and all vehicle occupants must be secured in an appropriate restraint system.

LPA Estoesta discussed and provided copies of of New Safe Sleep Brochure, Lead Poisoning Facts Flyer and California Child Safety Seat Law to the licensee.



Individual Medical Services (IMS) policy was discussed. 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

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility.

Effective August 1, 2003 California Law requires Family Child Care Home licensees 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 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail.
See LIC 809-C for continuation
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: DEVI, SHANTI
FACILITY NUMBER: 434408614
VISIT DATE: 03/04/2020
NARRATIVE
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The following is a viiolation was observed during the visit;

At 11:35 AM, LPA observed that there were two baby bouncer in the facility, one was found and sitting in the day care bedroom and one found and sitting in the living room. Licensee's daughter Geetam Das stated that the baby bouncers were not used very often. Advised licensee about the regulation in line using the baby bouncer in a Family Child Care Home and Licensee immediately removed the baby bouncers and placed them in the OFF limit area.

The licensee was reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.

Licensee is reminded that all assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. Licensee is encouraged to visit the Department’s website to access resources for Providers, Title 22 Regulations, Online option to pay Annual License fee, all forms can be downloaded, etc., at https://cdss.ca.gov/inforesources/child-care-licensing

For licensing updates, advised Licensee to email childcareadvocatesprogram@dss.ca.gov and request to be added to the email list. See LIC 809 D for the deficiency/ies cited on this visit. Advised licensee that failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected. This report shall remain on file for 3 years. A copy of the appeal rights was provided. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: DEVI, SHANTI
FACILITY NUMBER: 434408614
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2020
Section Cited

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102417 Operation of a Family Child Care Home. (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Section 1596.846
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(b) A baby walker shall not be kept or used on the premises of a child day care facility.(c) A "baby walker" means any article described in paragraph (4) of subdivision (a) of Section 1500.86 of Part 1500 of Title 16 of the Code of Federal Regulations.
This requirement is not met as evidenced by: Based on LPA observation, 2 baby bouncer found in the facility home during inspection, which poses a potential health and safety risk to children in care.
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Licensee stated that moving forward that any article known as a "baby bouncer," "walker-jumper," "baby walker: or any such similar article will not allowed in the facility.

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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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2020
LIC809 (FAS) - (06/04)
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