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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700012
Report Date: 07/07/2022
Date Signed: 07/07/2022 01:33:09 PM

Document Has Been Signed on 07/07/2022 01:33 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:THONDAPU, LAKSHMIFACILITY NUMBER:
015700012
ADMINISTRATOR:THONDAPU, LAKSHMIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 894-9689
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 10DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lakshmi ThondapuTIME COMPLETED:
01:45 PM
NARRATIVE
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On July 7, 2021 at approximately 9:00am Licensing Program Analyst (LPA) Haderer arrived unannounced and met with licensee Lakshmi Thondapu for the purpose of conducting an annual inspection. Present on arrival was the licensee, her fingerprint cleared and TB tested husband. Upon arrival there were 4 children in care, 6 more arrived during the inspection (3 infants; 3 two-years old; 3 three-years old; 1 five-years old); and two TB and fingerprint helpers also arrived. The facility is in ratio today. The hours of operation will be Monday-Friday, 8:30am to 6:00pm.

The home is a tri-level design, with 4 bedrooms, 3 bathrooms, family room, living room, dining room, kitchen, 2-car attached garage, front and backyards. Child gates are present and in use on all stair cases. The home is neat and clean with heating and ventilation for safety and comfort.



ON LIMIT AREAS remain as originally licensed: the fenced backyard, 1 ground floor bedroom, family room (day care area) and ground floor bathroom. The ISOLATION AREA will be in the bedroom on the bottom floor away from other children on care. Backyard is entirely fenced, with 2 locked sheds on the side yards and an additional plastic fence on the padded floor patio. The outdoor play area and child playhouses were found to be free from defects or dangerous conditions.

Off-limit-areas include: the entire 2nd and 3rd levels of the home that includes the kitchen, dining room, main living groom, all 3 upstairs bedrooms and bathrooms, front yard and 2-car attached garage. The off-limit areas will be made inaccessible by closed and/or locked doors, child gates, child-proof covers over doorknobs and through visual supervision.

Children’s and facility files were reviewed, 6 files were missing the LIC627 Consent for Emergency Medical Treatment form; 2 files were missing the LIC282 Notice of no Liability Insurance; 1 file was missing the LIC995A Parents Rights form. See LIC809D for Deficiencies.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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: THONDAPU, LAKSHMI
FACILITY NUMBER: 015700012
VISIT DATE: 07/07/2022
NARRATIVE
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The home has two fully charged fire extinguishers; a 2A10BC near the entrance door of the house; a 3A40BC in the family room (day care area). The home has appropriate smoke detectors and carbon monoxide detector (tested and working). There is a fireplace in the family room (day care area) that is fully blocked off with a screen and a bookcase for toys in front of it. The licensee conducts fire drills at least once each 6 months, the last drill was completed on June 9, 2022. Per licensee, there are no firearms in the home.

There are ample age appropriate toys in good condition and activities available for children. There is a small fountain in the corner of the backyard that is empty and not in use. Licensee is aware that fountain must always be kept empty. LPA did not observe any bodies of water, hazardous materials, or toxins accessible to children on the premises during the inspection.

The licensee’s Health and Safety training is completed, and CPR and First Aid certificate is current and expires 3/12/2024. Mandated Reporter is current and expires 07/15/2023. Assistant’s CPR and First Aid certificate are current and unexpired; Mandated Reporter is also current and unexpired. Licensee is in compliance with immunizations laws pertaining to family day care homes.

Licensee was reminded that CPR/1st Aide and Mandated Reporter training is to be 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
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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: THONDAPU, LAKSHMI
FACILITY NUMBER: 015700012
VISIT DATE: 07/07/2022
NARRATIVE
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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.

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.

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 are four deficiencies cited today, see LIC809D. The report will remain on file for three 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 Lakshmi Thondapu.

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

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 07/07/2022 01:33 PM - It Cannot Be Edited


Created By: Russell Haderer On 07/07/2022 at 12:56 PM
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: THONDAPU, LAKSHMI
FACILITY NUMBER: 015700012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(11)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (11) A signed statement regarding their criminal record history as required by Section 102370(c).

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 that assistants and volunteers do not have a signed Criminal Record Statement LIC508 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee to have volunteers and assistants provide their LIC508 form or collect a new one. These will be kept in the files for all current and future employees/assistants.
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 6 out of 12 files reviewed did not contain form LIC627 Consent for Emergency Medical Treatment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee to collect parents signatures on the required forms and going forward will ensure all children's files contain completed and signed forms.
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: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 07/07/2022 01:33 PM - It Cannot Be Edited


Created By: Russell Haderer On 07/07/2022 at 12:56 PM
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: THONDAPU, LAKSHMI
FACILITY NUMBER: 015700012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

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 out of 12 children's files was missing the signed receipt of the LIC995A which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee to collect a signed form and keep a record of receipt in the child's file, and all children's files going forward.

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: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 07/07/2022 01:33 PM - It Cannot Be Edited


Created By: Russell Haderer On 07/07/2022 at 12:56 PM
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: THONDAPU, LAKSHMI
FACILITY NUMBER: 015700012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

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 2 out of 12 children's files were missing the signed receipt of the LIC282 form Notice of No Liability Insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will collect signed forms for these two children's files and if still applicable in the future, all children's files going forward.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
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