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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500705
Report Date: 10/25/2022
Date Signed: 10/25/2022 11:05:50 AM

Document Has Been Signed on 10/25/2022 11:05 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:AKULA, LAXMIFACILITY NUMBER:
394500705
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
10/25/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Laxmi AkulaTIME COMPLETED:
10:45 AM
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On October 25, 2022, Licensing Program Analysts (LPAs) Stacey Williams met with Applicant, Laxmi Akula for the purpose of a pre-licensing inspection. Present during the inspection was Applicant’s husband. Criminal record clearances were verified.

LPA and Applicant toured the two-story home. The home consists of 4 bedrooms,3 bathrooms, livingroom, kitchen and dining area, laundry room and garage. Off limit areas: entire upstairs and the garage.

A copy of the control of property is on file. Applicant has completed the required Preventative Health and Safety course which includes 1 hour of nutrition and lead prevention training. LPA provided blank forms required for staff records as well as for children's records including LIC 9227- Individual Infant Sleeping Plan. Applicant has a designated Licensing Area where required forms such as Parent's Rights Notification, Emergency Disaster Plan, Earthquake Preparedness Checklist and the Facility Sketch is posted. This area is where Licensing forms/posters will be placed for parental review.

LPA and Applicant toured the outside facility. The backyard is fenced. There are no bodies of water on the property.

** Continued on subsequent page, LIC 809C **

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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 3
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: AKULA, LAXMI
FACILITY NUMBER: 394500705
VISIT DATE: 10/25/2022
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SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: AKULA, LAXMI
FACILITY NUMBER: 394500705
VISIT DATE: 10/25/2022
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SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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