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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500748
Report Date: 01/12/2023
Date Signed: 01/12/2023 12:16:25 PM

Document Has Been Signed on 01/12/2023 12:16 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:DESAI, PALLAVIFACILITY NUMBER:
394500748
ADMINISTRATOR:DESAI, PALLAVIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 490-3234
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
01/12/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pallavi DesaiTIME COMPLETED:
12:30 PM
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On January 12, 2023, at approximately 10:00 AM , Licensing Program Analyst (LPA) Stacey Williams met with Licensee, Pallavi Desai for the purpose of a pre-licensing change of location inspection. Licensee was previously licensed with facility number #013408764. All adult individuals subject to criminal background review have obtained a criminal record clearance. Licensee will be offering childcare services from Monday through Friday from 8:00 am to 6:00 PM.

Fire clearance has been granted by French Camp -McKinley Rural Fire Prevention Department on November 23, 2022.

LPA and Licensee conducted a health and safety inspection inside and out the home. The two-story home has an unfenced front yard, four bedrooms, three and half bathrooms, kitchen open to the eating area and family room, front dining room, laundry room, garage, and fenced backyard. The off-limits areas in the home are the entire upstairs and the garage. Licensee stated there are no pets in the home at this time. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. Functioning smoke and carbon monoxide detectors were observed in the home. Current pediatric CPR and first aid training was verified and expires on 11/20234. There is no fireplace in the home. LPA observed a 2-A:10-B:C fire extinguisher in the home. There are no bodies of water on the property. Supervision was discussed and applicant understands that children must be 100% supervised in unfenced yards. Immediate Civil Penalty regulation and deficiencies were reviewed. Licensing documents were posted in the entry area of the home. Licensee stated there are no weapons in the home.


LPA consulted the Licensee regarding personal rights. Licensee understands that corporal, physical and/or unusual forms of punishment is never allowed toward day care children or their own children during day care hours.


REPORT CONTINUED ON NEXT PAGE, LIC 809C
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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: DESAI, PALLAVI
FACILITY NUMBER: 394500748
VISIT DATE: 01/12/2023
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Licensee understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the written Unusual Incident Report (LIC 624) shall be submitted within seven days to remain in compliance.

LPA provided Licensee with Safe Sleep PIN 20-24-CCP and sleep logs for children under two years of age, reviewed Infant Individual Sleeping Plan (LIC 9227) for children under 12 months. LPA discussed current COVID-19 childcare guidelines with Licensee.

Licensee understands that children’s records are to be maintained according to Title 22 Regulations and be accessible to licensing for up to three years. Licensee understands that her License, Emergency Disaster Plan, and the Parents Rights Poster must be posted in the home.

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with applicant discussed 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 applicant the importance 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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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, LIC 809C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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: DESAI, PALLAVI
FACILITY NUMBER: 394500748
VISIT DATE: 01/12/2023
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LPA consulted applicant regarding the following topics: Safe Sleep, Type A vs. Type B deficiencies, complaints, LPA’s right to interview children without parental consent, civil penalties, incidental medical services, placement of detergents, placement of poisons, placement of medicines, announced vs. unannounced inspections, posting requirements, unusual incident reports, on-limits vs. off-limit areas, licensing file management, fire drills, 80% supervision, 100% supervision, fingerprint clearances, advertising, mandated reporting, and best practices.

LPA discussed the Immunization Regulations SB 792, the requirement that all individuals working or volunteering at a licensed Child Care Home must have vaccinations against, Pertussis, Measles and Influenza. Proof of required vaccines have been obtained from the Applicant.

LPA explained the requirement of AB1207 Mandated Reporter training. LPA explained that training must be completed once every two years. LPA observed that Mandated Reporter training certificate is current and in file.

Licensee understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that if anyone else works with the children, must also obtain the following: EMSA certified CPR and first aid training if left alone with the day-care children, and immunization for Measles, Pertussis and Influenza, and complete AB1207 Mandated Reporter Training.

Licensee understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

Licensee understands that the facility license is not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours. LPA explained to Licensee that if she moves and wants to continue to provide care, she must submit a change of location application, and have the new home inspected again.

Licensee understands that if she wants to make any changes to on or off limit areas in the home, she must notify licensing and LPA must do an inspection BEFORE children are allowed in the areas.

REPORT CONTINUED ON NEXT PAGE, LIC 809C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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: DESAI, PALLAVI
FACILITY NUMBER: 394500748
VISIT DATE: 01/12/2023
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LPA reviewed with applicant LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.


As of today, 1/122023 the facility is approved for a large Family Child Care Home license for a capacity to serve up to either 14 children, two (2) of which must be at least 6 years of age and no more than three (3) may be infants; or 12 children, four (4) of which may be infants. Infants are children under the age of 2.

Exit interview conducted and report was reviewed with Pallavi Desai.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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