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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422324
Report Date: 04/20/2023
Date Signed: 04/20/2023 02:50:14 PM

Document Has Been Signed on 04/20/2023 02:50 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SRIVASTAVA, JYOTIFACILITY NUMBER:
013422324
ADMINISTRATOR:SRIVASTAVA, JYOTIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 894-1322
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Licensee Jyoti SrivastavaTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Jyoti Saini met with Licensee, Jyoti Srivastava for an unannounced Annual Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during this inspection was Licensee and helper supervising, 12 children (I infant and 11 preschoolers). Licensee lives in the house with her husband and two children. The home is a two-story home with 3 bedrooms, 3 bathrooms, living room, family room, kitchen, dining room, laundry room, den, garage, and back yard. The hours of operation are 9:00am to 5:30pm, Monday -Friday.

Day care area: entire first floor which consist of living room, dining room, family room, kitchen, den (main daycare area), bathroom and backyard.


Off-limit-areas: entire second floor and garage. All off limit areas are inaccessible by closed and/or locked doors and visual supervision.
LPA inspected the house for health and safety hazards. Daycare Area is clean, orderly, and equipped with age appropriate toys and equipment for children, indoors and outdoors. Home has a working telephone, a working smoke and carbon monoxide detector, and a fire extinguisher. There are no bodies of water in the day care area. There is fireplace in the living room, which is not in use. There is a child safety gate located at the bottom of the stairs to prevent access to the stairs and upper levels to children in care. There are child size tables and chairs for snack and activities. Licensee is reminded of NO walker, exersaucers, jumpers, bouncers and any similar items to be used for children in care and shall be made inaccessible. The napping cots are in good condition and each child have their separate blankets. The blankets are washed weekly by the Parents. Licensee states there are no guns or weapons of any kind in the home. There are no pets in the home. The outdoor play area is fenced and is free from defects and dangerous conditions. Licensee and her helper have valid CPR. Licensee provides daily snacks and meal. Discipline policy is redirection. The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 04/12/2023. All required postings are properly posted. LPA discussed safe sleep guidelines and advised to start documenting 15 -minutes check.

see next page..

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SRIVASTAVA, JYOTI
FACILITY NUMBER: 013422324
VISIT DATE: 04/20/2023
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LPA reviewed 8 children’s files. All children have a record of emergency identification information and immunization record on file.

During Inspection, Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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.



Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com

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.

A notice of site visit was given and must remain posted for 30 days

There are no deficiencies cited today however, technical violations were given.

Exit interview conducted and report was reviewed with the licensee, Jyoti Srivastava.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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