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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414193
Report Date: 04/30/2024
Date Signed: 05/01/2024 09:39:07 AM


Document Has Been Signed on 05/01/2024 09:39 AM - 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:SIVASHANMUGAM, DHANALAKSHMIFACILITY NUMBER:
434414193
ADMINISTRATOR:SIVASHANMUGAM, DFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 986-1054
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY:14CENSUS: 8DATE:
04/30/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Dhanalakshmi SivashanmugamTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Anna Morales conducted an unannounced Annual Required Visit and was greeted by Licensee Dhanalakshmi Sivashanmugan. LPA also observed eight preschool aged children napping with supervision from 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 and her spouse. All adults have Criminal Background Check Clearances. Last disaster drill was conducted on April 12, 2024. LPA reviewed a Child Care Facility Roster. Licensee has current CPR and First Aid certification (expiration 1/21/2025).

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. LPA observed a swing play structure in the backyard that is secured to the ground and safe for the children.

LPA observed a 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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SIVASHANMUGAM, DHANALAKSHMI
FACILITY NUMBER: 434414193
VISIT DATE: 04/30/2024
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Incidental Medical services (IMS) policy was discussed. Staff stated that she does not administer any medications to the day care children at this time. 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.

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.

All food is provided by the Licensee. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored. Staff stated has a first aid kit in the day care. Staff stated that nobody smokes, and she understands that smoking is prohibited in the day care.

LPA reviewed a random selection of children's file and observed that parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification forms are in each file.

Licensee and Staff files were reviewed for the following records: Employee Rights (LIC9052), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza).

SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SIVASHANMUGAM, DHANALAKSHMI
FACILITY NUMBER: 434414193
VISIT DATE: 04/30/2024
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Supervision of children was discussed with licensee, and she understands that she must be present in the home during day care hours and ensure that the children are always supervised. Licensee understands her capacity options and she understand that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

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.



LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

The licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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 conducted and report was reviewed with the licensee. During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

There were no deficiencies cited at today's visit. One Technical Violation was issued during today's inspection for Mandated Reporter Training.

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.

SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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