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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415589
Report Date: 11/22/2021
Date Signed: 11/22/2021 08:41:25 PM

Document Has Been Signed on 11/22/2021 08:41 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GANESAN, UMADEVIFACILITY NUMBER:
434415589
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Umadevi GanesanTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Marilou Monico and Dung Mac, met with Licensee, Umadevi Ganesan, for an unannounced Required - 1 Year Inspection. LPAs were granted access to the home by the Licensee and toured indoor and outdoor areas during the inspection. Also present in the home were two adult helpers, licensee's eight-year-old son, and five (5) daycare children of whom two (2) were infants and three (3) preschool age. LPAs observed all required posted materials. Hours of operation for the facility are Monday – Friday, 8:00 AM to 6:00 PM. There are no active waivers or exceptions for this facility. Licensee states that the adults that reside in the home are herself and her husband.

Licensee was reminded that all adults 18 and over living or working in the home, 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. LPAs observed that licensee's adult helper, Athira Pillai Vijayalakshmi, was supervising napping children in the living room without fingerprint clearance. Athira states she worked at the facility on the following dates: 11/15/21, 11/17/21 and 11/22/21. The dates were confirmed by licensee. A civil penalty of $300.00 was assessed during the inspection.

LPAs observed a current facility roster (LIC9040). LPAs observed a fully charged 3A40BC fire extinguisher, functioning smoke detector and carbon monoxide detector. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. Licensee states that there are no weapons or firearms in the home.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes, Section 102417. 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 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
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: GANESAN, UMADEVI
FACILITY NUMBER: 434415589
VISIT DATE: 11/22/2021
NARRATIVE
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Indoor areas of the facility were inspected today and observed to be clean, orderly, and safe for the day care children. Off limit areas in the home: master bedroom, master bathroom, one bedroom, laundry room, garage, and kitchen. LPAs observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the home via sippy cups and bottles. LPAs observed that food brought from home were not labeled with the child's name. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 613-6950. Off limit areas outside the home: storage container located in the side yard


LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page 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 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.

Five (5) children’s files (2 infants and 3 preschool age) were reviewed during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), and Immunization Records (PM 286/CDPH 286). Per record review, four children (Child #2 thru #5) were missing immunization records.

Licensee's Mandated Reporter Training is expired. Helper #1 has no proof of Mandated Reporter Training. Licensee's CPR/First-Aid expires on July 24, 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years, website: www.mandatedreporterca.com. Assembly Bill (AB) 633 was discussed with licensee.

Continuation on next page:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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: GANESAN, UMADEVI
FACILITY NUMBER: 434415589
VISIT DATE: 11/22/2021
NARRATIVE
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Supervision of children was discussed with the Licensee and she understands that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that if she decides to transport children, children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Umadevi Ganesan.

As a result of todays inspection, deficiencies were cited on the following pages.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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Document Has Been Signed on 11/22/2021 08:41 PM - It Cannot Be Edited


Created By: Marilou Monico On 11/22/2021 at 03:41 PM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GANESAN, UMADEVI
FACILITY NUMBER: 434415589

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, Licensee's adult helper, Athira Pillai Vijayalakshmi, has been working in the home without fingerprint clearance. Athira worked in the home on the following dates: 11/15/21, 11/17/21, and 11/22/21. This poses an immediate risk to the health, safety or personal rights of children in care. Civil penalty of $300.00 was assessed during the inspection.
POC Due Date: 11/23/2021
Plan of Correction
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Licensee states she will submit a written plan by 11/23/21 to ensure that an adult must obtain fingerprint clearance prior to working in the home.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


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Document Has Been Signed on 11/22/2021 08:41 PM - It Cannot Be Edited


Created By: Marilou Monico On 11/22/2021 at 03:41 PM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GANESAN, UMADEVI
FACILITY NUMBER: 434415589

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(f)
Operation of A Family Child Care Home
(f) If food is brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, food brought from home were not labeled with the child's name. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 11/29/2021
Plan of Correction
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Licensee states she will submit a written plan by 11/29/21 to ensure that all food or beverages brought from home will be labeled with the child's name.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee's Mandated Reporter Training is expired and Helper #1 has no proof that she completed the Mandated Reporter Training. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee states she and her helper will complete the Mandated Reporter Training and will submit certificates by 12/22/21.
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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


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Page: 7 of 8
Document Has Been Signed on 11/22/2021 08:41 PM - It Cannot Be Edited


Created By: Marilou Monico On 11/22/2021 at 03:41 PM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GANESAN, UMADEVI
FACILITY NUMBER: 434415589

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Helper #1 is missing immunization in influenza or written statement declining the shot. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 11/29/2021
Plan of Correction
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Licensee states she will submit proof of immunization in influenza for Helper #1 by 11/29/21.
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Helper #1 is missing a signed and dated Notice of Employee Rights (LIC 9052). This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 11/29/2021
Plan of Correction
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Licensee states she will send a signed and dated LIC 9052 for her helper by 11/29/21.
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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/22/2021 08:41 PM - It Cannot Be Edited


Created By: Marilou Monico On 11/22/2021 at 03:41 PM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GANESAN, UMADEVI
FACILITY NUMBER: 434415589

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(11)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (11) A signed statement regarding their criminal record history as required by Section 102370(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, Helper #1 is missing completed and signed Criminal Record Statement (LIC 508) in her file. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 11/29/2021
Plan of Correction
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Licensee states she will submit a completed LIC 508 for Helper #1 by 11/29/21.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, Child #2 thru #5 are missing immunization records in their files. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee states she will ask parents to submit copies of children's immunization records and will submit a completed California School Immunization Record (PM 286/CDPH 286) for the four children by 12/22/21.
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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


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