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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394501562
Report Date: 05/22/2025
Date Signed: 05/23/2025 07:35:54 AM

Document Has Been Signed on 05/23/2025 07:35 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NUKANABOINA, LAXMI DEVIFACILITY NUMBER:
394501562
ADMINISTRATOR/
DIRECTOR:		NUKANABOINA, LAXMI DEVIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 246-1083
CITY:TRACYSTATE: CAZIP CODE:
95377
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/22/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Laxmi Devi NukanaboinaTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 05/22/2025, Licensing Program Analyst (LPA) Corina Beckby met with Applicant (A1) Laxmi Devi Nukanaboina for the purpose of a pre-licensing inspection. Applicant has also applied for a Large Family Child Care Home. Fire clearance was granted by South County Fire Authority Comm. Risk Reduction on 05/20/2025. LPA provided the Entrance Checklist to A1 and reviewed the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Applicant and all adults living in the home have criminal background clearance and was verified by LPA accessing Guardian. A1’s tentative hours of care are Monday through Friday, from 8:30 AM until 5:30 PM. A1 does not intend on providing overnight or weekend care.



A1 provided proof of control of property. A health and safety inspection were conducted inside and outside of the FCCH. A1 accompanied LPA for the entirety of the tour. The FCCH is a 2-story home with kitchen, storage closet, pantry, living room, nook, sitting room, laundry room, 2 1/2 bathrooms, 4 bedrooms, and garage. The OFF-limit areas are the garage, 2nd floor, pantry, all closets, kitchen, the backyard except the patio area, and front yard. A1 understands that OFF-limit areas must remain inaccessible to children in care. A1 understands if she wants to make any OFF-limit area an ON-limit area, she must notify Licensing and LPA must do an inspection BEFORE children are allowed in said area.

A dual functioning smoke and carbon monoxide detector was observed and tested. A 2A10BC fire extinguisher and first aid kit were observed. Safety latches are on all kitchen cabinets. The applicant understands that she must ensure the safety latches and gates are not broken. LPA discussed with the applicant that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock.

Continued on LIC809-C…

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Corina Beckby
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: NUKANABOINA, LAXMI DEVI
FACILITY NUMBER: 394501562
VISIT DATE: 05/22/2025
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LPA observed the stairs properly barricaded by a baby-gate at the first step at the bottom of the stairs. Fireplace has tempered glass making inaccessible to children. A1 states fireplace will not be used during day care hours. A1 stated there are no firearms or weapons in the home. A1 has a cat and will be in the garage during the day care hours. A1 understands she is responsible for ensuring the safety of the children from all pets.



LPA verified that toxic and hazardous items were inaccessible to children in care. The outdoor play area was toured. LPA verified that the entirety of the backyard is fenced-in and walked the perimeter to ensure the safety of the fence. A1 has a fishpond covered with wire fence which can hold an adults weight. LPA walked around the entire pond and ensured locking mechanism works properly making it inaccessible to children. LPA observed a sauna in the right side of the backyard that is off limits. LPA ensured no water or sharp objects were accessible in the sauna.

LPA discussed Mandated Reporter Training with A1. 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/. The training is currently provided in English and Spanish. A1 has a current Mandated Reporter Training Certificate which will expire on 03/06/2027. Current Pediatric CPR and First Aid training was verified and expires on 04/18/2027. Completion of Preventative Health and Safety training including nutrition and lead exposure was verified before the inspection. Proof of required immunizations for A1 are on file.

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) or (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.

Continued on LIC809-C…

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Corina Beckby
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: NUKANABOINA, LAXMI DEVI
FACILITY NUMBER: 394501562
VISIT DATE: 05/22/2025
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LPA discussed the Safe Sleep Regulations with A1 and 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 A1 of 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.

LPA discussed the requirement to check and log infant napping every 15 minutes for infants under 24 months. LPA provided a copy of the LIC 9227, Individual Sleeping Plan, to be completed for infants under 12 months.

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. A1 signed up for PIN’s at time of inspection.

A1 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.

A1 understands licenses are not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed. LPA reminded A1 to advise the department of any and all facility closures (vacations, holidays, and illness).



Continued on LIC 809-C...
NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Corina Beckby
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: NUKANABOINA, LAXMI DEVI
FACILITY NUMBER: 394501562
VISIT DATE: 05/22/2025
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A1 understands if an unusual incident occurs; Licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. A1 understands that if any structural changes are made to the FCCH; Licensing must be notified PRIOR to construction.



A1 understands annual licensing fees are due on the anniversary of receiving license. The annual fee for a small FCCH is $140.00 per year. A late fee of $70.00 is assessed the day after the anniversary date.

A1 understands that children’s and staff records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years. Records, postings, reporting requirements were reviewed. A1understands that a current roster must be maintained and that disaster drills must be conducted and documented once every six months. LPA discussed supervision, personal rights, criminal record clearances, staffing ratios and capacity, and maintaining buildings and grounds.

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.

A1 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.

On this date, 03/28/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. A1 stated she understood and is aware of all the information that was discussed and reviewed.

Effective today, 05/22/2025, Laxmi Devi Nukanaboina is approved for a Large Family Child Care License to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without assistant, the ratios revert to those for small family childcare home.

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Corina Beckby
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
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