434412038-6-27-2022-07-CC-MMOO-CFSTZR-20220627151047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434412038
Report Date: 06/27/2022
Date Signed: 06/27/2022 03:10:59 PM

Document Has Been Signed on 06/27/2022 03:10 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	TARE, MADHURA		FACILITY NUMBER:	434412038
ADMINISTRATOR:	TARE, MADHURA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 792-7014
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	14	CENSUS: 6	DATE:	06/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Madhura Tare		TIME COMPLETED:	03:25 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), Marilou Monico, conducted an unannounced Required - 1 Year Inspection. LPA met with Licensee, Madhura Tare, and explained the purpose of today's visit. Also present in the home were licensee's helper, licensee's two sons, licensee's daughter-in-law, one adult visitor, and six children (6) including four (4) infants, one (1) preschool age, and one (1) school age. LPA toured both indoor and outdoor areas with the Licensee during the inspection. LPA observed all required posted materials. Days and hours of operation for the facility are Monday – Friday, 9:00 AM- 5:00 PM. There are no active waivers or exceptions for this facility. Licensee states that there are five adults residing in the home: herself, her husband, her two sons, and her daughter-in-law. Licensee 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. LPA reviewed and obtained copy of facility roster (LIC9040). Fire/disaster drill was conducted on December 6, 2021. LPA observed a fully charged 2A10BC fire extinguisher, glass covered fireplace, functioning smoke and carbon monoxide detectors. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. Licensee states that there are no weapons or firearms in the home. 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 Continuation on next pages:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

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

FACILITY NAME: TARE, MADHURA	FACILITY NUMBER: 434412038
	VISIT DATE: 06/27/2022

NARRATIVE

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Indoor licensed areas of the facility were inspected by LPA today and observed to be clean, orderly, and safe for the day care children. Off limit areas in the home: all four bedrooms, 1 bathroom, furnace closet, and garage. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as table, chairs, and couches are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via sippy cups and individual water bottles. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 792-7014.

The outdoor licensed areas of the home were inspected and observed to be fenced in. Off limit areas outside the home: locked storage shed. There were no bodies of water observed.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page 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.

Five (5) children’s files were reviewed during today's inspection for the following records: Notification of Parents Rights (LIC995A), Affidavit Regarding Liability Insurance (LIC 282), Consent for Emergency Medical (LIC627), Identification and Emergency Information (LIC700), and Immunization Records.

LPA reviewed a helper's file. Licensee has current CPR/First Aid certifications with an expiration date of December, 2023. The Licensee has Mandated Reporter Training that expires on July 16, 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

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SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

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

FACILITY NAME: TARE, MADHURA	FACILITY NUMBER: 434412038
	VISIT DATE: 06/27/2022

NARRATIVE

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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

Exit interview conducted and report was reviewed with the Licensee, Madhura Tare.

As a result of today's inspection, deficiencies were cited on the following page.

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

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/27/2022 03:10 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: TARE, MADHURA	FACILITY NUMBER: 434412038
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

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 limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not having a current fire/disaster drill which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/01/2022
	Plan of Correction
1 2 3 4	Licensee states she will conduct fire/disaster drill with the children and will submit written documentation by 07/01/22.

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, licensee's helper (H1) is missing proof of immunization in pertussis (whooping cough). This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/27/2022
	Plan of Correction
1 2 3 4	Licensee states she will submit proof of immunization in pertussis for her helper by 07/27/22.

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

LIC809 (FAS) - (06/04)

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