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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500019
Report Date: 06/24/2021
Date Signed: 06/24/2021 12:54:18 PM

Document Has Been Signed on 06/24/2021 12:54 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, PALLAVIFACILITY NUMBER:
394500019
ADMINISTRATOR:MANE, PALLAVIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 413-7566
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
06/24/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Pallavi ManeTIME COMPLETED:
01:00 PM
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On Thursday June 24, 2021 at 10:30 A.M., Licensing Program Analyst (LPA) Stacey Williams conducted an unannounced random annual inspection and met with Licensee, Pallavi Mane. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. LPA observed that there were six children present in the facility during this inspection. Licensee's husband was also in the home during the inspection. Criminal record clearances were verified. The off-limit areas of the facility include the entire upstairs and the garage. Licensee acknowledged that children may never enter these off-limit areas.

LPA and Licensee toured the home inside and out. LPA observed current CPR/First Aid certification which expires 8/2022. LPA discussed recent changes in licensing requirements, posting COVID-19 material, licensing inspection notices and parent notification requirements. LPA reviewed child and staff files. LPA provided Licensee with the updated safe sleep PIN 20-24-CCP and a blank Infant Individual Sleeping Plan (LIC9227) for her records.

LPA observed fire drills were conducted at least once every six months and documented. Hazardous materials, chemicals, and medications are kept inaccessible to children. Fire extinguisher meets regulation guidelines. Smoke detector and carbon monoxide detector are operational.

There were no bodies of water observed.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

REPORT CONTINUED ON NEXT PAGE

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2021
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: MANE, PALLAVI
FACILITY NUMBER: 394500019
VISIT DATE: 06/24/2021
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LPA discussed Mandated Reporter Training (AB1207 Training) with Licensee. Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: HTTP://WWW.MANDATEDREPORTERCA.COM/. LPA observed current Mandated Reporter Training certification.

LPA checked facilities fees and confirmed that it is up to date.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the Licensee can obtain updated licensing information, new regulations and access forms. LPA advised Licensee of their responsibility to stay current in regard to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws CHILDCAREADVOCATESPROGRAM@DSS.CA.GOV

No Title 22 Deficiencies observed in the areas that were evaluated. LPA reviewed report with the Licensee and provided copies along with Appeal Rights. An exit interview was conducted. Notice of Site Visit was provided to the Licensee and shall be posted in the facility for 30 days.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC809 (FAS) - (06/04)
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