434414193-7-2-2021-07-CC-AMOS-C4JNGC-20210702102654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414193
Report Date: 07/02/2021
Date Signed: 07/02/2021 10:27:02 AM

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:	SIVASHANMUGAM, DHANALAKSHMI		FACILITY NUMBER:	434414193
ADMINISTRATOR:	SIVASHANMUGAM, D		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 986-1054
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95054
CAPACITY:	14	CENSUS: 6	DATE:	07/02/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dhanalakshmi Sivashanmugan		TIME COMPLETED:	10:40 AM

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) Anna Morales conducted an unannounced Annual Required Visit and was greeted by Licensee Dhana Sivashanmugan. LPA also observed six day care children, one at 19 months and five between the ages of two to four years old. Also, present were two staff. Days and hours of operation are Monday - Friday from 9:00 AM to 5:30 PM. Adults over the age of 18 and residing in the home are the Licensee, her spouse. Licensee has two children between the ages of 11 and 17 years of age. All adults have Criminal Background Check Clearances, signed Criminal Record Statements LIC508 on file with Licensing Office. 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 inside the home: one bedrooms- upstairs. Master bedroom, master bathroom, 2 bedrooms, kitchen/dining room, barricaded fireplace (located in the living room), and attached garage. The stairs were barricaded. Off limit area outside the home: left side area of the backyard. LPAs observed a swing play structure in the backyard that is secured to the ground and safe for the children. Last disaster drill was conducted on 1/20/21 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 weapons in the home. Licensee has a dog which is kept separate from the children. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. (page 1).

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

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 3

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: SIVASHANMUGAM, DHANALAKSHMI	FACILITY NUMBER: 434414193
	VISIT DATE: 07/02/2021

NARRATIVE

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LPA's reviewed three of the Emergency Information Cards(LIC700) which were complete and updated. 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 violation within a 12-month period.

Incidental Medical Services (IMS) policy was discussed. The Licensee stated that she currently does not have any children in care who requires IMS and doesn't take care of children who are sick. Licensee has an isolation room for children who get sick while at day care. 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 does have current Mandated Reporter Certificate. The last Mandated Reporter Certificate expired for Licensee on 2/28/2022 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 atwww.mandatedreporterca.com.

Licensee does not a current CPR and First Aid card. It expired on 2/21/2023.
Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov (page 2)

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: SIVASHANMUGAM, DHANALAKSHMI	FACILITY NUMBER: 434414193
	VISIT DATE: 07/02/2021

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	Continued from 809c page 2. No deficiencies are being cited based on the LPAs observations, interviews conducted and records reviewed in accordance with the California Code of Regulations Title 22. LPA conducted an exit interview with the Licensee . A NOTICE OF SITE VISIT WAS ISSUED, AND TO BE POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3