<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422890
Report Date: 08/03/2021
Date Signed: 08/03/2021 04:33:53 PM

Document Has Been Signed on 08/03/2021 04:33 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:KOTPALLIWAR, VIJAYAFACILITY NUMBER:
013422890
ADMINISTRATOR:KOTPALLIWAR, VIJAYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 579-4399
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
08/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:59 PM
MET WITH:Vijaya KotpalliwarTIME COMPLETED:
04:35 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 August 3, 2021 at approximately 3:59pm Licensing Program Analyst (LPA) Russ Haderer met with licensee Vijaya Kotpalliwar for the purpose of conducting an announced inspection to view new on-limits and off-limits areas of the home. Present for today’s inspection was licensee’s fingerprint and TB cleared husband, their 16 year old daughter and 12 year old son and 4 children in care today, all toddlers ages 2 to 4.

The licensee recently had some additions made to the home and therefore required a visit to view and approve the new on-limit areas. The licensee also asked to adjust former on-limits areas and change them to off-limits.

New On-limit-areas include: Foyer/Entry area; Office, Bedroom 3 (Day care area); Jack and Jill bathroom attached to new laundry room; Laundry room, Family room; backyard. Licensee reminded that other than wipes or things used for the children in the on limits children’s bathroom, they need to be empty of most all items (or locked up) such as cleaning products and laundry soaps. There are no accessible hazardous cleaning chemicals or other liquids in the on-limits area.

New Off-limit-areas include: 3 bedrooms (including the master bedroom w/bathroom), living room, Kitchen, dining room, main house bathroom, hallway for bedrooms, detached garage, gated right and left side yards. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. Licensee is aware she must contact licensing so that an inspection can be completed prior to changing an off limits area to on limits.


The new on-limits and off-limits as described above are approved as of this day, August 3, 2021.

LPA left facility at 4:35pm.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2021
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 1