434413618-4-6-2023-07-CC-AMOS-CQMT7K-20230406142853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413618
Report Date: 04/06/2023
Date Signed: 04/06/2023 02:29:02 PM

Document Has Been Signed on 04/06/2023 02:29 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	TIRUVALLUR, KRISHNAVENI V		FACILITY NUMBER:	434413618
ADMINISTRATOR:	TIRUVALLUR, KRISHNAVENI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 439-8191
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	14	CENSUS: 10	DATE:	04/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Krishnaveni Tiruvallur		TIME COMPLETED:	11:25 AM

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Licensing Program Analyst (LPA) Anna Morales conducted an unannounced Annual Required visit and was greeted by Licensee Krishnaveni Tiruvallur and spouse Raghunandan Tiruvallur. The Day care hours are hours of operation are Monday - Friday, 8:30am - 5:00pm. The Licensee, spouse, daughter and son-law reside at the home. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Last disaster drill was completed on March 20,2023.

LPA observed two infants (over 12 months) and 10 preschool aged children (2-4 years old). The children were engaged with activities.

LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. The front room is the main day care area where there are tables, sufficient materials, toys, and play equipment for the day care children. One bedroom is used for the children for rest and naps. In the backyard, LPA observed a trampoline ( with a net around it), and the Licensee stated that he follows the manufacturer instructions and the children are supervised at all times while in use. The home is clean and orderly. LPA did not observe any wall heaters or fire place inside the home, Off limit areas inside Licensee's home:. three bedrooms, hallway bathroom, master bathroom, kitchen and garage. LPA observed a fully charged fire extinguisher, and a working smoke/carbon monoxide detector No bodies of water observed. The Licensee states that he does not have any weapons. All detergents, cleaning compounds, poisons, medications, and other similar items are out of reach and inaccessible to children. Licensee states that he does not administer medications at this time. Licensee has a pet dog which does not interact with the children in care.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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

FACILITY NAME: TIRUVALLUR, KRISHNAVENI V	FACILITY NUMBER: 434413618
	VISIT DATE: 04/06/2023

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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. Licensee has an area where sick children can be isolated from the others until parent pickup.

Licensee's Mandated Reporter Training (AB1207) expired in 2014. Licensee's and Spouse Mandated Reporter Training (AB1207), training is being waived as English their spouse's second language. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

A random selection of children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization Records (PM286). LPA was unable to review the required 15 minute document for C2.
Licensee's files were reviewed for the following records: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Licensee and spouse have a current First Aid/CPR on file and it expires on 1/2025.
LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes 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

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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

FACILITY NAME: TIRUVALLUR, KRISHNAVENI V	FACILITY NUMBER: 434413618
	VISIT DATE: 04/06/2023

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LPA discussed the requirements of AB 633 with the Licensee and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Exit Interview was conducted with Licensee. A Technical Violation was issued for: LPA was unable to observe documentation for C2, 15-minute checks. No deficiencies were cited at today's inspection.

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

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/inspection-process

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

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