<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500068
Report Date: 01/11/2022
Date Signed: 01/11/2022 12:56:43 PM

Document Has Been Signed on 01/11/2022 12:56 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:HIREMATH, ASHWINIFACILITY NUMBER:
394500068
ADMINISTRATOR:HIREMATH, ASHWINIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 833-0880
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
01/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Ashwini Hiremath TIME COMPLETED:
12:45 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 January 11, 2022, Licensing Program Analyst (LPA) Stacey Williams conducted a case management inspection for the purpose of making an off limit area in the facility on limits. LPA met with Licensee, Ashwini Hiremath. LPA observed 8 children supervised by Licensee and her two Assistants.

LPA and Licensee toured the home. LPA was shown the bedroom suite area Licensee is requesting to be on limits. The area has one bedroom, one living space, one bathroom and a kitchenette. The stove and oven will have security mechanisms to cover knobs and the outside of the oven. There is a back door that leads to the side of the house that will have a third additional dead bolt lock. Current off limit areas of the facility will now be: entire upstairs, kitchen, and the study.

Licensee will submit photos to LPA once the security mechanisms are installed.


Exit interview was conducted and notice of site visit was provided to Licensee to post for 30 days.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2022
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 1