015700420-2-6-2024-52-CC-JJAN-D27SP8-20240206130243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015700420
Report Date: 02/06/2024
Date Signed: 02/06/2024 01:02:54 PM

Document Has Been Signed on 02/06/2024 01:02 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 CC RO, 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: 6	CENSUS: 3	DATE:	02/06/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Anurag Kansal		TIME COMPLETED:	01:05 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 02/06/2024 at 10:05AM Licensing Program Analyst (LPA) Jaleesa Jackson met with Licensees husband Anurag Kansal for an Unannounced Required Inspection Visit. Present during the inspection was the Licensees husband, her fingerprint cleared assistant, and 3 infants. Also residing in the home are the Licensees minor children. Licensee was temporarily away from home and not present during today's inspection due to a prior appointment. Licensee was made aware of the inspection via phone call by husband. The Licensee's home was toured for a health and safety inspection. The facility operates 8:00AM to 6:00PM, Monday – Friday. ON LIMITS AREA: Living Room, Kitchen, Dining Area, Hallway to Daycare area, Day care Room (room in the back of the house, Bathroom #1 (attached to day care room), nap room (first room to the right of day care hallway), and fenced off area Backyard OFF LIMITS AREA: Two (2) Bedrooms, Bathroom #2, Master Bedroom with attached Full Bathroom, the side of the backyard and Garage. Off limits rooms are made inaccessible by closed doors, gates and visual supervision. ISOLATION AREA: Couch in Dining room The facility is a single-story home owned by the Licensee. The inside of the home is observed to be neat, clean with ample age appropriate materials for the children. During today inspection all toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. There is a fully charged 3A40BC fire extinguisher, working combination monoxide detector/smoke detector, and telephone. The home does not contain a fireplace. Facility representative stated that there are no firearms or pets or no one who smokes at the home. LPA did not observe any bodies of water in or around the home. Continued on 809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

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 CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: AGARWAL, SURBHI	FACILITY NUMBER: 015700420
	VISIT DATE: 02/06/2024

NARRATIVE

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LPA reviewed 3 children's files and that all were complete. LPA reviewed and obtained a copy of child's roster. Licensee is operating within the licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed. Licensee has current Pediatric CPR First Aid that expires 12/2024. Licensee’s Mandated Reporter training is complete and expires 9/11/2024 . Both the Licensees husband and assistant have required health and safety training. Mandated Reporter is completed for both as well. LPA observed that the last disaster and fire drill were completed at least every six months. The last disaster and fire drill were both conducted on 9/8/2023. All required postings are made visible. Facility representatives were able to provide all required documents while Licensee was temporarily away. Licensee was present to sign the report when she arrived at 12:55PM.

There were no deficiencies cited on today's inspection.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.
Facility representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed facility representative 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.

Continued on 809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

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 CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: AGARWAL, SURBHI	FACILITY NUMBER: 015700420
	VISIT DATE: 02/06/2024

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Surbhi Agarwal via phone, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

Exit interview conducted and report was reviewed with the facility representative Anurag Kansal and Surbhi Agarwal.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

LIC809 (FAS) - (06/04)

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