394500019-6-3-2021-53-CC-SWIS-C3N2NL-20210603173256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 394500019
Report Date: 06/03/2021
Date Signed: 06/03/2021 05:33:02 PM

Document Has Been Signed on 06/03/2021 05:33 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	MANE, PALLAVI		FACILITY NUMBER:	394500019
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	06/03/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Pallavi Mane		TIME COMPLETED:	02:30 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 June 3, 2021at 1:30 PM, Licensing Program Analyst (LPA), Stacey Williams met with Licensee, Pallavi Mane via FaceTime video conferencing due to the COVID-19 pandemic. The purpose of the tele-visit was to conduct an increase of capacity inspection. Licensee applied to change from a Small Family Child Care Home to a Large Family Child Care Home. LPA observed three daycare children present in the home with Licensee and the Licensee’s husband. All adults have criminal record clearances.

The two-story home has an unfenced front patio, 4 bedrooms upstairs and 1-bedroom downstairs which is where care will be provided, 2 bathrooms upstairs and 1 bathroom downstairs for children to use, a living room, dining room, kitchen, garage, and fenced backyard. The off-limits areas in the home are: garage and entire upstairs of the home. Off-limits areas will remain inaccessible to children. Licensee acknowledged that children may never enter the off-limit areas. Licensee acknowledged that if she would like to change an off-limits area to on-limits, she will inform LPA for inspection and approval prior to using the space. Licensee stated there are no new residents in the home since licensure.

During the tele-visit inspection, LPA requested a tour of the facility. LPA and Licensee conducted a health and safety tour inside and out the home. A functioning smoke and carbon monoxide detectors and fire extinguisher were observed in the home. The Fire Safety Inspection Clearance has been cleared by French Camp McKinley Rural FPD as of 5/2/21.

REPORT CONTINUED ON NEXT PAGE

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: MANE, PALLAVI	FACILITY NUMBER: 394500019
	VISIT DATE: 06/03/2021

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
26
27
28
29
30
31
32

LPA observed that there were no hazardous items accessible to children. Licensee stated that she understands that any poisons must be kept under lock and key. LPA observed that cleaning materials were inaccessible. Licensee stated there are no weapons in the home. Toys appear to be safe. The backyard is fenced.

This facility evaluation report was reviewed and discussed with the Licensee. Records, postings and reporting requirements were discussed. LPA discussed safe sleep regulations and COVID-19 Update Guidance: Childcare Programs and Providers as well as Licensee’s current best practices regarding sanitizing the home, hand washings and wearing face coverings. Licensee was encouraged to visit the department website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, self-assessment guides, regulations and legislation pertaining to family child care homes. .

Effective today 6/3/21, facility is approved for a Large Family Child Care License to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without assistant, the ratios revert to those for small family childcare home.

An exit interview was conducted. Facility evaluation report and Notice of Site Visit was emailed to Licensee for receipt, acknowledgement and signature.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2