434416350-12-7-2022-07-CC-AMOS-CLVVBC-20221207151719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416350
Report Date: 12/05/2022
Date Signed: 12/07/2022 03:17:27 PM

Document Has Been Signed on 12/07/2022 03:17 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	SINGH, PALLAVI		FACILITY NUMBER:	434416350
ADMINISTRATOR:	SINGH, PALLAVI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(669) 264-6788
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 9	DATE:	12/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Pallavi Singh		TIME COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts Anna Morales conducted an ANNUAL REQUIRED visit and was greeted by Licensee Pallavi Singh and three staff. Also present were nine children children ( four are under two years of age). LPA observed a current children roster. Last disaster drill was conducted on 10/24/2022 Days and hours of operation are Monday - Friday from 8:45am- 6:15pm. The licensee is the only Adult residing in the home and she has a Criminal Background Check Clearance, signed Criminal Record Statement LIC508 on file with Licensing Office. LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. The facility is a single story home. LPA observed the main area of the home to be used for the day care will be in the two rooms. There are two bedrooms that will be used for napping. There is one bathroom in the hallway for the children's use. *There are two bedrooms, one bathroom and kitchen that will be off limits.* The children have access to the backyard which is enclosed by a fence The Licensee has a designated area in the home where a child(ren) can be isolated if exhibiting signs of illness. There are no wall heaters observed. LPA observed a fully charged fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. Licensee stated that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. (page 1)

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SINGH, PALLAVI	FACILITY NUMBER: 434416350
	VISIT DATE: 12/05/2022

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. Licensees stated that she does not take care of any children who are ill. 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.

Licensee and staff have current Mandated Reporter Training on file. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

A random selection of children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization Records (PM286).

Licensee and a random selection of staff files were reviewed for the following records: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Licensee does have a current First Aid/CPR on file and it expires on 11/2023,

LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes 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

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SINGH, PALLAVI	FACILITY NUMBER: 434416350
	VISIT DATE: 12/05/2022

NARRATIVE

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LPA discussed the requirements of AB 633 with the Licensee and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Exit Interview was conducted with Licensee, no deficiencies are being cited based on the LPA's observations, interviews conducted and records reviewed in accordance with the California Code of Regulations Title 22.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

LIC809 (FAS) - (06/04)

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