434416757-2-3-2022-07-CC-MMOO-CBAQZJ-20220203113650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416757
Report Date: 02/03/2022
Date Signed: 02/03/2022 11:36:58 AM

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:	ANJALI, FNU		FACILITY NUMBER:	434416757
ADMINISTRATOR:	FNU, ANJALI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 650-2406
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95130
CAPACITY:	14	CENSUS: 0	DATE:	02/03/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Fnu Anjali		TIME COMPLETED:	11:45 AM

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	On February 3, 2022 at 8:56 AM, Licensing Program Analyst (LPA) Marilou Monico conducted an announced Prelicensing Inspection. LPA met with Fnu Anjali, Applicant, and explained the nature of today's visit. Also present in the home was applicant's husband. 9:00 AM - Application/Record Review: The adults that reside in the home are the Applicant and her husband. Applicant's twin children ages four years old also reside in the home. The Applicant resides in a two-storey, four-bedroom and three-bathroom house. Days and hours of operation will be Monday to Friday from 8:00 AM to 6:00 AM. The Applicant's CPR and First Aid certification is current, with an expiration date of December 11, 2023. Applicant's Mandated Reporter Training for Child Care Workers expires on January 15, 2024. The Applicant leases the home and copy of lease agreement was submitted to Licensing. All individuals subject to a criminal record review have obtained a criminal record and child abuse index clearances prior to today's inspection. 9:20 AM - Physical Plant tour: There is a working telephone in the home (408) 650-2406. The home is clean and has heating and ventilation for safety and comfort. The off limit areas inside the home: entire upstairs (Bedrooms #3 & 4, bathroom, & family room), one bathroom downstairs, and garage. Off limit areas outside the home: both side yards, two storage sheds, and right side section of the backyard. There are safe and age appropriate toys, play equipment, and materials for the children. The Applicant has a designated area in the home where a child(ren) can be isolated if exhibiting signs of illness. The home has working smoke/carbon monoxide detectors. The Applicant has a fire extinguisher (3A40BC) in the home that is fully charged. There is a fireplace in the living room that is barricaded. The Applicant states that she does not have any firearms in the home. All cleaning compounds, sharp objects, medications, and other similar items are stored inaccessible to the children. The Applicant understands that baby walkers, baby bouncers, jumpers, and saucer chairs are not allowed in the home. The Applicant states that no one in the home smokes and she understands that smoking is prohibited in the home. The Applicant has a first aid kit. There were no bodies of water observed. Continuation on next pages:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

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 3

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: ANJALI, FNU	FACILITY NUMBER: 434416757
	VISIT DATE: 02/03/2022

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
26
27
28
29
30
31
32

9:50 AM - Kitchen tour: The refrigerator and freezer in the home is clean. The Applicant understands that any food/drink which is brought by parent(s) of day care child(ren) must be properly labeled with the child(ren) name and properly stored or refrigerated.

10:00 AM - Bathroom tour: The toilet and sink are clean, safe, and operable. Sharp objects and cleaning products are stored inaccessible to children.

10:05 AM - Document/Regulation Review: A Family Child Care Home packet with updated Licensing forms was provided to Applicant. Documents from the packet, including but not limited to the following were discussed and reviewed with the Applicant: 1) Child Care Facility Roster (LIC 9140) must be complete and current at all times, 2) Fire/disaster drills must be practiced at least once every 6 months and documented on the fire/disaster drill log provided to the Applicant, 3) Posting requirements - Parent's Rights (PUB 394), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), and Facility License, 4) Staffing & Ratio - capacity/ratio limitations handout, 5) Lead Flyer Requirement (PIN 20-01-CCP), and 6) Forms and Records to keep in your Family Child Care Home (LIC 311D).

LPA discussed the safe sleep regulations with Applicant 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 informed Applicant 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.

Applicant states that she will talk to the children and will use redirection as forms of discipline. The Applicant understands that children's personal rights should not be violated; including no corporal punishment, supervision of children, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed with the Applicant.

Continuation on next page:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ANJALI, FNU	FACILITY NUMBER: 434416757
	VISIT DATE: 02/03/2022

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
26
27
28
29
30
31
32

Incidental Medical Services (IMS) policy was discussed with the Applicant. 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 (USDOJ) 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. The Applicant states that she does not plan on administering medication to the day care children at this time.

10:45 AM - Notification requirements/civil penalty: LPA discussed the requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised her of 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. LPA advised Applicant 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.

LPA conducted an exit interview with Applicant, Fnu Anjali, and advised her that a license for a Small Family Child Care Home will be granted pending manager's review and approval.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3