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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422890
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:46:33 AM

Document Has Been Signed on 08/03/2022 11:46 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
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: 7CENSUS: 4DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Vijaya KotpalliwarTIME COMPLETED:
11:50 AM
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On August 3, 2022 at approximately 9:00am Licensing Program Analyst (LPA) Russ Haderer met with licensee Vijaya Kotpalliwar for the purpose of conducting an unannounced annual inspection. Living in the home is the licensee, her fingerprint and TB cleared husband, and their two adolescent children. Present today was the licensee, her husband, son and 4 children in care (2 infants and 2 toddlers), the home is in ratio today. The hours of operation are Monday-Friday, 8:30 AM to 6:00PM.

The facility is a single story 3-bedroom, 2 bathroom home with a laundry room, kitchen, living room, study/office, daycare area, entryway/foyer with an additional small office and detached 2-car garage. Toxins, medicines, and hazardous items were inaccessible during today's inspection. Per the licensee, the ISOLATION AREA will be in the office area attached to the foyer where licensee can see and monitor the child away from the other children in care.



The home is neat and clean, with heating and ventilation for safety and comfort. The outdoor play area is fenced and free from defects and dangerous conditions and has a new shed. There were ample age appropriate toys that were observed to be safe and in good condition. LPA did not observe any bodies of water, hazardous materials, or toxins accessible to children on the premises during the inspection.

On-limit-areas include: Foyer/Entry area; Office, Bedroom 3 (Day care area); Jack and Jill bathroom attached to laundry room; Laundry room; Family room; and 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.
Off-limit-areas include: 3 bedrooms (including the master bedroom w/bathroom); living room; Kitchen; dining room; main house bathroom; hallway for bedrooms; detached 2-car garage; gated right and left side yards. Off limit areas are inaccessible by closed and/or locked doors and visual supervision.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KOTPALLIWAR, VIJAYA
FACILITY NUMBER: 013422890
VISIT DATE: 08/03/2022
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There is a fully charged 3A40BC fire extinguisher mounted in the day care area, working (tested) carbon monoxide and smoke detectors, telephone, and a first aid kit. There is a screened fireplace in the off limits living room. Per licensee, there are no firearms in the home. The licensee conducts and documents Fire/Disaster Drills at least twice a year, and the log indicates a drill was conducted 5/22/2022. All required licensing documents are framed and posted and visible for public review.

Licensee carries childcare liability insurance, the policy is in effect through 9/16/2022.

Children's files were reviewed and found to be complete and in good order. One child’s file contained an unsigned consent for medical treatment form, see LIC809D for deficiency. The facility roster was reviewed, and a copy obtained. The Licensee’s Health and Safety training is completed, pediatric CPR/First Aid certificate is current and expires 05/15/2023. Licensee has proof of required immunizations, and mandated reporter (verified AB1207), expires on 09/15/2023. The licensee is in compliance with the immunization laws which pertains to day care providers.

LPA reminded the licensee of the following; Mandated Reporter training is to be renewed every two years, CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.



Incidental Medical Services (IMS) policy was discussed. 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

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.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KOTPALLIWAR, VIJAYA
FACILITY NUMBER: 013422890
VISIT DATE: 08/03/2022
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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.

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.

There was one deficiency found in inspection, see LIC809D: This report will remain on file for 3 years.

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

Exit interview conducted and report was reviewed with the licensee Vijaya Kotpalliwar.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/03/2022 11:46 AM - It Cannot Be Edited


Created By: Russell Haderer On 08/03/2022 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KOTPALLIWAR, VIJAYA
FACILITY NUMBER: 013422890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of the 7 children's files reviewed one child's file contained the completed LIC627 Consent for Medical Treatment form but it was not signed and dated which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee will collect the parents signature on the consent form and going forward ensure all medical consent forms are signed and dated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


LIC809 (FAS) - (06/04)
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