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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622033
Report Date: 10/27/2023
Date Signed: 10/27/2023 11:14:44 AM

Document Has Been Signed on 10/27/2023 11:14 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SIDHAYE, DEEPTIFACILITY NUMBER:
393622033
ADMINISTRATOR:SIDHAYE, DEEPTIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 358-1717
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
10/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Deepti SidhayeTIME COMPLETED:
11:30 AM
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On October 27, 2023, Licensing Program Analyst (LPA) met with Licensee, Deepti Sidhaye for the purpose of conducting a case management inspection. LPA observed five children ( 2 infants) supervised by Licensee and her two Assistants. Criminal record clearances were verified.

LPA and Licensee discussed an unusual incident report that was called into Community Care Licensing on October 26, 2023. LPA obtained information pertaining to the incident during today's inspection.

Exit interview conducted and report was reviewed with the Licensee, Deepti Sidhaye. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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