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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010208682
Report Date: 03/16/2023
Date Signed: 03/16/2023 10:35:43 AM

Document Has Been Signed on 03/16/2023 10:35 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SINGH, PURNIMAFACILITY NUMBER:
010208682
ADMINISTRATOR:SINGH, PURNIMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 843-5612
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
03/16/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Purnima SinghTIME COMPLETED:
10:40 AM
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On March 16, 2023 at 8:54am, Licensing Program Analyst (LPA) Indira Loza arrived unannounced on a case management inspection to place the facility from Inactive status to Active status. LPA Loza met with Licensee Purnima Singh. Only the Licensee was present for the inspection. Living in the home is the Licensee, and the Licensee's ex-husband. There are no children in care during todays inspection. LPA conducted a health and safety check. Operating hours will be Thursday through Sunday from 3:30pm-11:30pm.

The home is single family home with three bedrooms and three bathrooms, a living room, kitchen, a den, and a communal area straight from the kitchen. The bathroom past the kitchen is newly constructed. The on limit areas will be the living room, kitchen, the den, the communal area, and the bathroom past the kitchen. The off limit areas will be the all three bedrooms, two bathrooms, and the backyard which will be blocked by locked doors, a safety gate, and visual supervision. There are no pools, hot tubs or any other bodies of water during today's inspection. The ISOLATION AREA will be the couch in the living room.

The home has a fully charged 2A10BC fire extinguisher, a working smoke detector, and a working carbon monoxide detector in the communal area past the kitchen.The Licensee has a working telephone. Per Licensee, there are no firearms in the home. The Licensee has a current CPR/First Aid certificate which expires on February 2025.

Before the License can be turned to Active status the following needs to be completed by April 14, 2023
- Current Mandated Reporter Certificate

Exit interview conducted with Licensee Purnima Singh
Report, notice of site visit, and Appeal rights provided to the Licensee.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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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