015700420-2-9-2023-52-CC-MPRE-CNVPYX-20230209104440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015700420
Report Date: 02/09/2023
Date Signed: 02/09/2023 10:44:56 AM

Document Has Been Signed on 02/09/2023 10:44 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:	AGARWAL, SURBHI		FACILITY NUMBER:	015700420
ADMINISTRATOR:	AGARWAL, SURBHI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 764-7978
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	02/09/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Surbhi Agarwal		TIME COMPLETED:	10:40 AM

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 2/9/2023 at 8:30am Licensing Program Analyst (LPA) Morgan Pringle met with Applicant Surbhi Agarwal for an Announced Pre-Licensing Visit for a Large Family Child Care Home. Present during the inspection was the Applicant and her husband. Applicant lives in the home with her husband Anurag Kansal, their fourteen (14) year old son and eleven (11) year old daughter. The Applicant’s home was toured for a health and safety inspection. The facility plans to operate 7:30– 6:00pm, Monday – Friday. ON LIMITS AREA: Daycare Hall (living area in the back of the home), Daycare Room (Room attached to Daycare Hall, Daycare Bathroom and Backyard OFF LIMITS AREA: Living Room, Kitchen, Dining Area, Two (2) Bedrooms, One (1) full Hallway Bathroom, Master Bedroom with attached Full Bathroom and Garage ISOLATION AREA: Daycare Room The facility is a single-story home owned by the Applicant. The home consists of a kitchen, living room, dining area, three (3) full bathrooms, four (4) bedrooms, daycare hall (“living room like” room in the back of the home), garage and backyard. The home was granted a fire clearance on 2/3/2023 from the Fremont Fire Department with the condition of daycare not permitted in the garage. The inside of the home is observed to be neat, clean with ample age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. All off limit areas in the home will be blocked off with closed doors and gates. All sleeping equipment is clean, free from defects, and properly maintained. Applicant has stated that there are no firearms and no pets in the home. The home has centralized heat, plenty of windows and will be using portable fans for the hotter months. LPA did not observe any harmful bodies of water in or around the home.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: AGARWAL, SURBHI	FACILITY NUMBER: 015700420
	VISIT DATE: 02/09/2023

NARRATIVE

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The backyard is clean, free from hazards and fully fenced. There are two (2) areas to the backyard, one (1) area is adjacent to the daycare hall and the other area is adjacent to the street. There will be ample age appropriate materials for the children that are clean, well maintained and with no defects.

There is a 3A40BC fire extinguisher in the hallway of the childcare areas. There is a working smoke/carbon monoxide detector in the daycare hall, the daycare room, the hallway in the daycare area, all three (3) bedrooms, the hallway of the main home and in the living room. The Applicant’s Health and Safety training with the lead poisoning component has been completed and Pediatric CPR and First Aid certificates are current and expires on 12/3/2024. Mandated Reporter training is complete and expires on 9/11/2024. All adults living in the home have obtained a criminal record clearance. Applicant has provided immunizations for influenza, measles, pertussis and has a current record of tuberculous.

Applicant was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. Applicant was reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Applicant 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: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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: AGARWAL, SURBHI	FACILITY NUMBER: 015700420
	VISIT DATE: 02/09/2023

NARRATIVE

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LPA discussed the safe sleep regulations with Applicant 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 Applicant 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.

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.

LPA reviewed with Applicant the LIC311D, Forms/Records To Keep In Your Family Child Care Home, Children’s Forms/Records, Facility Forms/Records, and Information to be Posted.

Entrance checklist was provided to the Applicant.

Exit interview conducted and report was reviewed with the Applicant Surbhi Agarwal.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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