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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408614
Report Date: 04/02/2024
Date Signed: 04/02/2024 06:26:14 PM


Document Has Been Signed on 04/02/2024 06:26 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:DEVI, SHANTIFACILITY NUMBER:
434408614
ADMINISTRATOR:DEVI, SHANTIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 887-3649
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:14CENSUS: 4DATE:
04/02/2024
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Geetam DasTIME COMPLETED:
05:15 PM
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On 4/2/2024 at 3 pm, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced Required 1 Year Inspection. LPA met with the Licensee's daughter Geetam Das. Present on this visit were Licensees's Assistants SamJhan and Mariah, 3 infant and 1 preschool child. The facility currently operates from Monday to Friday 9 AM to 5 PM.

The home was toured to conduct a Health and Safety Inspection. 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 living room, family room, bedroom number 1 (for napping), dining room, kitchen, hallway bathroom and the backyard. The BACKYARD play area is completely fenced.
The OFF-LIMIT AREAS are bedroom number 2 and 3, 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 bedroom number 1.

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 required fire extinguisher, working smoke detector, working carbon monoxide detector and working telephone. The fireplace is blocked by children's activity equipment to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills, the Licensee conducted on 3/20/2024. Licensee owns the house, does not carry childcare liability insurance or a bond and maintain the signed form LIC 282 on each children's file
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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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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: 04/02/2024
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The licensee completed the CPR and First Aid Training and certificates expires on March 2025. The licensee and the licensee's ssistants completed the Mandated Reporter General Training and Child Care Providers training online at https://mandatedreporterca.com/ LPA reminded the Licensee's daughter to maintain the Licensee and Licensee's assistants records of Measles and Pertussis immunization, Influenza vaccination and TB clearance on their file. LPA reminded Licensee daughter that only the Influenza vaccination can be decline with a written declination.

Facility roster of children was reviewed. Children’s files were reviewed, which included records of receipt for Parents' Rights Notice, Identification and Emergency Information, Consent for Emergency Medical Treatment form, LIC 9150, Infant Sleep Log and Immunization. The licensee is in ratio today. Licensee stated that she does not transport children at this time.

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.

Licensee's daughter 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.

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

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
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: DEVI, SHANTI
FACILITY NUMBER: 434408614
VISIT DATE: 04/02/2024
NARRATIVE
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LPA Estoesta discussed again to the Licensee's daughter of the PIN 20-24-CCP RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT, Child Care Providers AB 1207 - CALIFORNIA CHILD CARE PROVIDERS: MANDATED REPORTER TRAINING https://mandatedreporterca.com/training/child-care-providers and the Staff Immunization.

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.

Type B deficiency were cited on this visit, please see LIC 809 D.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee's daughter, Geetam Das.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/02/2024 06:26 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: DEVI, SHANTI
FACILITY NUMBER: 434408614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)


This requirement is not met as evidenced by: During the LPA's file review, Infant child # 2 and 3 did not have a completed LIC 9227 on their file. The infants mentioned were enrolled when they were under 12 months old. LPA reminded the Licensee's daughter of the PIN 20-24-CCP RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT.
Deficient Practice Statement
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Based on the file review, the licensee did not comply with the section cited above in 2 out of 2 in iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2024
Plan of Correction
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The Licensee will require the infants parents to complete the LIC 9227 and the License will maintain the forms on the children's file by the POC date above. Licensee will submit the evidence to the Licensing Office.
Type B
Section Cited
CCR
102416(c)


This requirement is not met as evidenced by: During the LPA file review, 2 assistant's did not have any training certificate on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. At 3:45 pm, LPA observed 2 mentioned assistants were left alone with the children. The Licensee's daughter came in to the facility at 4 pm.



Deficient Practice Statement
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Based on the LPA's file review, the licensee did not comply with the section cited above in 2 out of 2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2024
Plan of Correction
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The Licensee will require to have one of the assistant's to enroll and complete the pediatric cardiopulmonary resuscitation and pediatric first aid by the POC date and will submit the evidence to the Licensing Office.
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 JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5