<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416723
Report Date: 05/17/2023
Date Signed: 05/17/2023 05:41:46 PM

Document Has Been Signed on 05/17/2023 05:41 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:SINGH, POOJAFACILITY NUMBER:
434416723
ADMINISTRATOR:POOJA, SINGHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 442-8503
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
05/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:31 PM
MET WITH:Pooja SinghTIME COMPLETED:
05:55 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 Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Other inspection. LPA met with Licensee Pooja Singh and explained the reason for the inspection. The purpose of this inspection is due to infant safe sleep.

LPA observed that Licensee's child, who is infant age was sleeping on the second floor. Her assistant nor herself were on the same floor as the infant. LPA also observed that there was a mobile hanging above the crib. LPA discussed with Licensee that the infant safe sleep regulations apply to her own child. LPA also discussed with Licensee that she or her assistant needs to be on the same floor as sleeping infants.

As a result of this inspection, two Type B citation was issued. Exit interview conducted and report was reviewed with Licensee Pooja Singh. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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 2
Document Has Been Signed on 05/17/2023 05:41 PM - It Cannot Be Edited


Created By: Samantha Yip On 05/17/2023 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: SINGH, POOJA
FACILITY NUMBER: 434416723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2023
Section Cited
CCR
102425(j)(6)

1
2
3
4
5
6
7
Infant Safe Sleep. The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall be on the same floor as the sleeping infant.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
By POC 05/24/2023, Licensee will submit written plan on how she will ensure that she or her assistant is on the same floor as sleeping
8
9
10
11
12
13
14
Based on observation, Licensee's child, who is infant age, was sleeping on the second floor. Both Licensee and her assistant were not on the same floor, which poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14
infants.
Type B
05/24/2023
Section Cited
CCR102425(b)(3)

1
2
3
4
5
6
7
Infant Safe Sleep. Cribs or play yards shall be free from all loose articles and objects. There shall be no objects hanging above or attached to the side of the crib.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
By POC 05/24/2023, Licensee will submit proof that there is nothing hanging above the crib.
8
9
10
11
12
13
14
Based on observation, LPA observed that there was a mobile hanging above the crib, which poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14
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:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2