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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314038
Report Date: 09/15/2022
Date Signed: 09/15/2022 12:44:04 PM

Document Has Been Signed on 09/15/2022 12:44 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:UTHAYAKUMAR, SUBAFACILITY NUMBER:
304314038
ADMINISTRATOR:UTHAYAKUMAR, SUBAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 292-3882
CITY:LAKE FORESTSTATE: CAZIP CODE:
92679
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
09/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:LicenseeTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted an announced in-person Pre-Licensing inspection for a change of location from licensed facility # 304311246 for a Large Family Child Care home. LPA met with Licensee, Suba Uthayakumar and her spouse, Sandirasegaram who provided a tour of the new home.
A review of the Facility Personnel Report Summary indicates adult residents, who require caregiver background check clearances, transfers, exemptions have been obtained and they are cleared.
Applicant stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. Applicant was reminded if changes, to notify the licensing office.

Applicant is requesting for a Large Family Childcare Home License. Operation hours will be Monday to Friday from 7:30 AM to 6:00 PM and care and supervision will be provided to children ages 3 months to 3 years old.

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a 2 story single home with 5 bedrooms, 5 1/2 bathrooms, Living room, dinning room, family room areas, kitchen and one bedroom and children's bathroom are on the 1st floor. Upstairs are off limits.
Areas that will be used by children were inspected for safety, comfort, cleanliness, ventilation and heating. Telephone service (cell phone is the primary contact phone) .

Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children stored in the locked garage and top cabinets. The Licensee states (that there are no poisons on the premises). Applicant was advised that any poisons
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038
VISIT DATE: 09/15/2022
NARRATIVE
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must be locked with a key or combination lock.

Based on the Facility Sketch submitted, areas off limits to children and parents are: Licensee has designated the family room on the first level of the house as children's area which this area will be barricaded from the kitchen are by a baby. There is one bedroom on the first floor which is off limit to children.

Areas Designated for Day care activities: Parents and children shall enter the home, through the main entrance door, leading to 1st floor. The applicant has designated the down the stairs area for day care children. There is children's bathroom on the first floor. The designated day care area is family room. The living room and dinning room are also designated for nap area for children which will be gated from the kitchen area. Children's area is for eating, playing, and activities. beddings are provided by the applicant. Licensee and shall provide ongoing supervision during nap time. Licensee stated children are allowed to come to living room and dinning area. No hazardous observed in the children's area, living room and dinning room. Children's bathroom was free of hazardous items.

Garage door is on the first floor which is located in the off limit area and is inaccessible to children by a baby gate which is installed at the entrance of the kitchen hallway. stairs.

Licensee will use the Cell phone for Day care activities and applicant was informed if a cell phone is used for child care, it must remain on the premises at all times during hours of operation.



Licensee was informed and understands the home is to be free from smoking during hours of operation.
Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

The applicant has provided the proof of control of property to LPA..

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038
VISIT DATE: 09/15/2022
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The full bathroom is located in the designated room for children's use with There is a cabinet under the sink with no hazardous items. The children's bathroom was observed to be safe and free of hazardous items.

Licensee will provide AM/PM snacks and parent provide lunch to children. If food is brought from home and these containers shall be labelled with their names by the parents and stored accordingly.

Upon entrance through the designated main door of the home, applicant shall receive the children here, due to pandemic parents are encouraged to follow CDC guidelines,

OUTDOOR PLAY AREA: Applicant will use the large back yard which is located on the 1st level for outdoor activities. It is fenced with metal fence and wall. Flooring covered with concrete. No equipment observed for outdoor area. The licensee will send pictures.

There are no pets, firearms, weapons, bodies of water in the home.

The fire extinguisher did not meet the licensing requirements. The applicant was advised to provide the right size of 2A10 BC fire extinguisher. Smoke and carbon monoxide detectors were tested and are operable. Applicant stated he fire extinguisher will be stored in the kitchen and out of reach of children on the first floor. Smoke detector/ Carbon Monoxide is mounted on the ceiling of the passage area on the first and second level of the house.



Applicant has completed the required Mandated Reporter Child Abuse training, Health and Safety training with Nutrition and Lead Poisoning component and Pediatric First Aid and CPR which is valid through 07/2024.

The following was discussed with the applicant: In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification, TB clearance along with a valid criminal record clearance associated to the facility license.
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038
VISIT DATE: 09/15/2022
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Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated. The fire extinguisher type 2A-10 BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Fire and safety drills must be performed every six months and documented for review by the Department. Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

No smoking, No Johnny jumpers, No Baby walkers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

Applicant shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian



LPA discussed the following items with the Applicant, Suba Uthayakumar during the Exit interview:

Criminal Record statement: Applicant, Suba Uthayakumar 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.
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038
VISIT DATE: 09/15/2022
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Safe Sleep : LPA discussed the safe sleep regulations with applicant, Suba Uthayakumar & 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 of the applicant, Suba Uthayakumar 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.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: 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: http://www.ada.gov/childqanda.htm.

Review of records to be maintained : LPA reviewed with Applicant, Suba Uthayakumar the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. (LPA gave the LIC 311D with all the required forms and Fire logs to be maintained in the home). A packet of enrollment for children and posting forms were printed out and were given to applicant.

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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 license- related information to l

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

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038
VISIT DATE: 09/15/2022
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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/process.


OTHER INFORMATION AND FORMS PROVIDED: Capacity Handout for a Small and Large Family Child Care Home. LPA explained the age requirements for the enrolled children ensuring that when there are 8 children, at least one child is enrolled in Kindergarten or 6 years old, to be in compliance with Title 22 requirements and additional forms were given to the applicant.

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment. The facility at the time of Pre-licensing inspection is not in compliance for a (Large Family Child Care Home) with Title 22 Regulations

The following corrections shall be sent to the Department before issuing a license.



(1) Installation of sturdy gates in front of kitchen so it will be inaccessible to children.
(2) Pictures of the entertainment set when TV is installed.
(3) Installation of gate in front of the stairs to make upstairs inaccessible to children.
(4) Installation of fence in the back yard area to make the bush area and slope inaccessible to children.
(5) Installation of two gates in front of the side yards to make it inaccessible to children.
(6) A picture taken of the toys and equipment for children's use in the back yard including cushioning materials under the equipment such as slide or climbing structure.
(7) A picture of complete items for posing requirements.
(8) Installation of lock on the downstairs bedroom to make it inaccessible to children.
Applicant shall submit the above corrections within 30 days of today's report to LPA via email.
Final License shall be approved upon receiving the above corrections and final approval from the management. .
Exit interview was held with applicant/Licensee, Suba Uthayakumar and appeal rights were presented.
End of report,
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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