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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412078
Report Date: 08/18/2021
Date Signed: 08/18/2021 10:59:48 AM

Document Has Been Signed on 08/18/2021 10:59 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:AGRAWAL, SARIKAFACILITY NUMBER:
434412078
ADMINISTRATOR:AGRAWAL, SARIKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 306-1927
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sarika AgrawalTIME COMPLETED:
11:10 AM
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Licensing Program Analysts (LPAs) Mel Matos and Cortney Nelson met with Sarika Agrawal, Licensee, for unannounced Required – 1 year annual inspection (KIT 1). LPAs were granted access to the home by the Licensee. LPAs also observed eight preschool day care children and one adult assistant (Lavejeet Kaur) in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements. LPAs observed the required postings, including the facility license, near the front entrance to the home. The home has a working telephone. Days and hours of operation are Monday - Friday from 9:00 AM to 5:30 PM. The Licensee and her spouse (Pushpendra Agrawal) are the adults residing in the home. Licensee's CPR and First Aid certifications are current and expire in May 2023. A copy of her CPR and First Aid certifications was provided to LPAs during today's inspection.

LPAs reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on August 2, 2021. The Licensee has the required immunizations (MMR, Tdap, & flu) and is current with her Mandated Reporter Training for Child Care Workers training (expiration: 02/17/22). A copy of her training certificate was provided to LPAs during today's inspection. LPAs reviewed eight children's files and observed current and updated Identification and Emergency Information (LIC 700) and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. The Licensee states that a child will be isolated in the living room if needed to because of illness or communicable disease.

Safe sleep update: LPAs discussed the new “Safe Sleep” regulations with the Licensee and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee. LPAs reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 08/18/2021):
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AGRAWAL, SARIKA
FACILITY NUMBER: 434412078
VISIT DATE: 08/18/2021
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 08/18/2021):

LPAs toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPAs observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. There are no stairs or wall heater units inside the home. Off limit areas in the home are the 3 bedrooms, master bathroom, fireplace unit (located in the living room), and attached garage. Off limit areas outdoors are the barricaded air conditioner unit and water heater closet.

LPAs observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does not have any pets and weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. The Licensee states that she does not have any poisons in the home. The Licensee states that she does not administer any medication to the day care children at this time.

A review of staff records on August 17, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPAs also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time without a fully qualified adult present. The Licensee understands that she must comply with the capacity and ratio requirements of the small Family Child Care Home License whenever there is only one fully qualified adult present. The Licensee states that does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.
LPAs conducted an exit interview with the Licensee and advised her that no deficiencies issued during today's inspection. The Licensee agreed to submit copies of her Tdap, Mmr, and flu vaccines and updated Emergency Disaster Plan (LIC 610A) to LPA Matos by Friday August 20, 2021.
A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC809 (FAS) - (06/04)
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