434415074-6-2-2022-07-CC-PHEZ-CEZTSC-20220602145855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415074
Report Date: 08/24/2021
Date Signed: 06/02/2022 02:59:28 PM

Document Has Been Signed on 06/02/2022 02:59 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:	SRIVASTAVA, MALA		FACILITY NUMBER:	434415074
ADMINISTRATOR:	SRIVASTAVA, MALA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(425) 445-4367
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	14	CENSUS: 9	DATE:	08/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:32 PM
MET WITH:	Mala Srivastava		TIME COMPLETED:	03:20 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 Analysts (LPA) Pete Hernandez conducted an unannounced required 1 year inspection to the home today. LPA met with Licensee, Mala Srivastava, and explained the nature of today's visit. At the time of arrival the Licensee had 4 infants and 5 preschool aged children with her. Days and hours of operation are Monday – Friday from 8:30AM- 5:00PM. The Licensee states that she and her husband, Akhilesh Srivastava, are the only adults that live in the home. Licensee’s and CPR/ First Aid expire on 05/18/2023. LPA toured the indoor and outdoor areas of the home during today's visit. LPA observed the required posted documentation. LPA obtained and observed a current Child Care Facility Roster. The Licensee stated that she conducts Fire Drills every two months and the most recent was done 6/4//2021. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Off limit areas inside the home: The two bedrooms and master bedroom and bathroom and Garage. Off limit areas outside the home: none. LPA observed a charged 3A40BC fire extinguisher in the kitchen area. LPA observed operational smoke and carbon monoxide detectors and fire pull stations. LPA observed a barricaded fireplace. The Licensee stated that there are no firearms in the home. Detergents, cleaning compounds are inaccessible to children. A review of Staff records indicates that all persons that require a caregiver background check have received criminal record and child abuse index clearance or exemption. LPA informed Licensee of the applicable civil penalties for any adult who has not received fingerprint clearances, is not associated to the license and who comes in contact with or provides 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. REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 08/24/2021):

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

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: SRIVASTAVA, MALA	FACILITY NUMBER: 434415074
	VISIT DATE: 08/24/2021

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (REPORT DATED 08/24/2021):
Provider to lock and secure jacuzzi tub before license for small family child care will be approved and granted.
LPA reviewed eight (5) children’s files. All children have the required documentation.
The Licensee has not completed the required Mandated Reporter training (AB1207). The Licensee state that she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.
LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. 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.

Licensee has current Mandated Reporter Certificate.The Mandated Reporter expires 8/16/2023. 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.

Copy of children's roster was provided.

LPA discussed the new requirements for caring for infants and the LIC9227 form.

LPA Reviewed 6 of 9 children's files. All the files were complete with required documentation.

LPA reviewed the files of the Licensee and the Helper. All the files were complete with all of the required documentation. Mala's Mandated Reporter certificate is current and expires on 8/21/2023. Neetu's expires on 7/8/2023

Type A language: Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC809 (FAS) - (06/04)

Page: 3 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: SRIVASTAVA, MALA	FACILITY NUMBER: 434415074
	VISIT DATE: 08/24/2021

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (REPORT DATED 08/24/2021):

LPA discussed the requirements of AB 633 with the Licensee/Director (provide name) and provided the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and the Licensee/Director understands the requirements. Upon receipt, Licensee/Director (provide name) shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

LPA also discussed "zero tolerance" related regulations with the Licensee/Director, (provide name) and was advised of the assessment for 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.

Type A language: Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, An exit interview was conducted with the licensee. A copy of this report were discussed and left with the Licensee, Mala Srivastava, whose signature on this form confirm receipt of these documents.

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

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC809 (FAS) - (06/04)

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