434410211-5-10-2019-07-CC-MSMS-BC2QEK-20190510120627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434410211
Report Date: 05/10/2019
Date Signed: 05/10/2019 12:06:32 PM

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:	MATANGI, SUPRIYARAJ		FACILITY NUMBER:	434410211
ADMINISTRATOR:	MATANGI, SUPRIYARAJ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 221-6691
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95054
CAPACITY:	14	CENSUS: 10	DATE:	05/10/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Supriyaraj Matangi		TIME COMPLETED:	12:15 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) Mel Matos met with Supriyaraj Matangi, Licensee, for an unannounced annual/random inspection. LPA also observed two adult assistants, Licensee's adult son, and ten day care children (2 infants & 8 preschool) in the home during today's inspection. Days and hours of operation are Monday - Friday from 8:30 AM to 5:45 PM. The adults that reside in the home are the Licensee, Licensee's spouse, Licensee's adult son, and Licensee's adult daughter. Licensee's certifications for CPR and First Aid are current and expire in March 2020. LPA reviewed the Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on November 14, 2018. LPA reminded the Licensee to keep her roster current at all times. LPA reviewed nine children's files and observed current and updated immunization records and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. LPA observed that the Licensee has record of Mmr & Tdap vaccinations as well as the opt out form for the flu vaccine. The Licensee also has proof of completion of the Mandated Reporter training for Child Care Workers. LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters inside the home. Off limit areas in the home: 3 bedrooms, 2 bathrooms, office room, barricaded fireplace, and attached garage. There are no stairs inside the home. Off limit areas outside the home: right & left side yards and two locked sheds. The Licensee has a swing structure in the backyard that is secured to the ground and safe for the day care children. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 05/10/2019):

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
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: MATANGI, SUPRIYARAJ	FACILITY NUMBER: 434410211
	VISIT DATE: 05/10/2019

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

CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/10/2019):

LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. The Licensee states that she does not have any weapons in the home. The Licensee states that she has one dog (Border Collie mix) that is kept in the off limits garage and left side yard during day care hours. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. The Licensee states that she does not administer any medications to the day care children.

A review of staff records on May 9, 2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time with a qualified assistant present. The Licensee states that she does not transport any children.

No deficiencies issued during today's inspection.

LPA conducted an exit interview with the Licensee prior to the conclusion of today's inspection and the Licensee agreed to email copies of her vaccinations and proof of completion of the Mandated Reporter Training for Child Care Workers to LPA by Friday May 17, 2019.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
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)

Page: 2 of 2