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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075700233
Report Date: 06/20/2022
Date Signed: 06/20/2022 09:54:04 AM

Document Has Been Signed on 06/20/2022 09:54 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:NAYAK, USHAFACILITY NUMBER:
075700233
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/20/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Usha NayakTIME COMPLETED:
10:05 AM
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On June 20, 2022 at 9:00am, Licensing Program Analyst (LPA) Julia Placencia arrived for a case management inspection. LPA met with licensee Usha Nayak. There were no children in care today.

The purpose of today's inspection was to observe a change licensee made to the layout of the day care rooms. There are no changes to the On Limit and Off Limit rooms, however, licensee has changed the main day care room to the master bedroom at the rear of house. Previously the main day care room was the left bedroom at the front of the house.

There are no deficiencies cited today.

Exit interview conducted with licensee Usha Nayak and copy of report provided. A notice of site visit was provided and must remain posted for 30 days.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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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