013419864-10-2-2024-52-CC-LDBX-D9NQ85-20241002115609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013419864
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:56:15 AM

Document Has Been Signed on 10/02/2024 11:56 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	KULKARNI, POORNIMA		FACILITY NUMBER:	013419864
ADMINISTRATOR/ DIRECTOR:	KULKARNI, POORNIMA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 797-7325
CITY:	FREMONT	STATE: CA	ZIP CODE:	94555
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 3	DATE:	10/02/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:25 AM
MET WITH:	Poornima Kulkarni		TIME VISIT/ INSPECTION COMPLETED:	12:20 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	On October 2, 2024, at approximately 10:25 AM Licensing Program Analyst (LPA) Lorraine Dacanay Breaux met with licensee Poornima Kulkarni for an Unannounced Annual 1 Year Required Inspection. LPA disclosed the purpose of the inspection and was granted entry into the home by the licensee. LPA provided the LIC 126. Present today were three (3) toddler age children and two (2) fingerprint cleared assistants. LPA toured the home to conduct a health and safety inspection. Hours of operation are 8:30am - 6:00pm Monday through Friday. The 2 story home consists on four (4) bedrooms, three (3) bathrooms, Living Room, Family Room (day-care) kitchen, Sun room, Backyard, side yard and two car garage. The home was neat and orderly, with heating and ventilation for safety and comfort. Licensee does have current child care insurance and expires 5/5/2025. Per licensee does not provide care for children under 3 years old and must be potty trained. On limit areas include: Livingroom and Family Rooms (Daycare areas) Dining room area, downstairs half bathroom (right of entry way), sun room and backyard. ISOLATION AREA: Sun room away from the children in care, until the parents arrive. There is a fireplace in the family room that is covered to prevent access to children while in care. Off-limits areas include: Entire second level of home including all bedrooms, side yard, kitchen and two car garage. The off limits area and will be made inaccessible by closed and/or locked doors, gates and visual supervision. There is a gate present at the bottom of the stairs to prevent access to the second level of the home. There are no pools, hot tubs or any other bodies of water present in the home. Licensee confirmed there are no pools/bodies of water at the home during today's visit. Licensee confirmed resides in the home. LPA did not observe any hazardous materials or toxins accessible to children. There are age appropriate toys that appear to be safe and in good condition. Per licensee, there are no firearms in the home during today's inspection. Per licensee does not provide transportation. 809-C

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KULKARNI, POORNIMA	FACILITY NUMBER: 013419864
	VISIT DATE: 10/02/2024

NARRATIVE

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Records: At 11:10AM LPA requested and reviewed 1 child's files and personnel records. There is a current roster available for review. Licensee CPR/First Aide is current and expires on 7/22/2025 and Mandated Reported completed on 4/17/23. Licensee is reminded that CPR/first Aide and Mandated Reporter is to be renewed every two years for all employees/staff.

CCLD Inspection Process: 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.

Criminal Record Clearance: Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Safe Sleep: 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. (currently does not provide care for children's under age of 3 years per licensee)

LIC 809-C

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KULKARNI, POORNIMA	FACILITY NUMBER: 013419864
	VISIT DATE: 10/02/2024

NARRATIVE

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Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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/resources/child-care-centers/.

Per licensee does not provide medication at this time.

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

Megan’s Law: During the exit interview, the licensee, Poornima Kulkarni confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Unusual Incident/Student Injury Report: Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

No deficiencies cited during today's inspection.

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. Appeal Rights provided. Exit interview conducted and report was reviewed with the licensee, Poornima Kulkarni.

Page 3 of 3 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

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