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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500705
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:26:53 PM

Document Has Been Signed on 10/29/2024 12:26 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AKULA, LAXMIFACILITY NUMBER:
394500705
ADMINISTRATOR/
DIRECTOR:		AKULA, LAXMIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 223-7860
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 10DATE:
10/29/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Laxmi AkulaTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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On October 29, 2024, Licensing Program Analyst (LPA) Stacey Williams conducted an unannounced annual random inspection and met with Licensee, Ashwini Hiremath. LIC (126) Entrance Checklist for Family Childcare Homes was provided and reviewed with Licensee. Licensee and her Assistant were observed supervising 10 children. Facility hours of operation are from 9:00am – 5:00 pm five days a week. Licensee stated she does not provide overnight care. Facility fees are current. Criminal record clearances have been verified.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Childcare Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.



A health and safety inspection was conducted in all areas accessible to children. Upon entry, LPA observed the posting of the facility license, Emergency Disaster Plan, Earthquake Preparedness Checklist and Notification of Parent Rights. The OFF-limit areas are upstairs and the garage. Off-limits areas will remain inaccessible to children by way of gate and closed doors.

Continued on LIC809-C...
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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Document Has Been Signed on 10/29/2024 12:26 PM - It Cannot Be Edited


Created By: Stacey Williams On 10/29/2024 at 11:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AKULA, LAXMI
FACILITY NUMBER: 394500705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Licensee will ensure that all Assistants have current CPR/First Aid certification on file by POC due date- 11/29/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bettina Engelman
LICENSING EVALUATOR NAME:Stacey Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


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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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AKULA, LAXMI
FACILITY NUMBER: 394500705
VISIT DATE: 10/29/2024
NARRATIVE
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Licensee acknowledges that she must contact LPA prior to making an off-limits area on-limits and vice versa.

Toys appear to be safe and in working order. Cleaning agents and detergents are made inaccessible to children. Poison, toxic and hazardous times are made inaccessible to children. Functioning smoke and carbon monoxide detectors were observed in the home and meet Title 22 regulations. LPA observed a 2A-10BC fire extinguisher. Sharp utensils are inaccessible to children. Licensee understands that she must ensure the safety locks are not broken. The backyard is fenced and has sufficient toys. Licensee states there are no weapons in the home. There are no bodies of water on the premises. Licensee states there are no pets in the home.

LPA did not observe a current roster and advised Licensee of the requirement to update the facility roster as students enroll/end enrollment. LPA observed a fire drill log that indicated drills are being conducted at least two times per year. LPA reviewed children’s files which obtained all required documents aside from LIC 995A. Licensee will provide parents a copy of the form at pickup on today’s date and request signature. Preventative health training and current pediatric CPR and first aid training, and immunization records was verified for Licensee. Licensee’s Assistant that is present does not have CPR/First Aid certification on file. CPR for Licensee expires 6/2026. Mandated Reporter Training was discussed. Mandated Reporter training is current for Licensee and her Assistant. Mandated Reporter training must be completed once every two years, and training is accessible at www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.



LPA discussed the safe sleep regulations with Licensee and provided the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee, of the importance

Report continued on LIC809-C...
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AKULA, LAXMI
FACILITY NUMBER: 394500705
VISIT DATE: 10/29/2024
NARRATIVE
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of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. LPA encouraged Licensee to visit the department website at WWW.CCLD.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes.

During the exit interview, the Licensee, Laxmi Akula confirmed there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California. LPA reminded Licensee to advise the department of any and all facility closures (vacations, Holidays, and illness).

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Report continued on LIC 809-C...
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AKULA, LAXMI
FACILITY NUMBER: 394500705
VISIT DATE: 10/29/2024
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In the areas that were evaluated, deficiencies were observed and will be cited on subsequent page, LIC 8089D

An Exit interview was conducted, and the report was reviewed with Licensee, Laxmi Akula. LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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