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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420281
Report Date: 01/12/2023
Date Signed: 01/19/2023 01:11:14 PM

Document Has Been Signed on 01/19/2023 01:11 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:VARSHNEY, MINAKSHIFACILITY NUMBER:
013420281
ADMINISTRATOR:VARSHNEY, MINAKSHIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 573-0809
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 18DATE:
01/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Minakshi VarshneyTIME COMPLETED:
06:00 PM
NARRATIVE
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**THIS IS AN AMENDED REPORT**

On today's date, 1/12/2023 at 1:35PM, Licensing Program Licensing Program Analyst (LPA) Melanie Otsuji arrived to the facility unannounced on another matter and observed licensing violations. Present during today's visit were 2 fingerprint cleared staff members, the Licensee, 1 adult without the proper criminal record clearance and 18 children (9 preschoolers, 9 infants)(cited on another report).

During LPA's tour of the facility, LPA noted that a room within the garage had a adult male present and residing inside (T1) without the proper criminal record clearance. After speaking with the Licensee, LPA was informed of another male individual (T2) that has resided temporarily in the facility without the proper criminal record clearance.

See 809-D for the TYPE A deficiency that is cited on today's visit. An exit interview was conducted. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. LIC9224 provided to Licensee.

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 newly enrolled at the facility during the next 12 months.

Exit interview conducted with Licensee, Minakshi Varshney.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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Document Has Been Signed on 01/12/2023 05:43 PM - It Cannot Be Edited


Created By: Melanie Otsuji On 01/12/2023 at 03:20 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: VARSHNEY, MINAKSHI
FACILITY NUMBER: 013420281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2023
Section Cited
CCR
102370(d)(1)

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102370(d)(1) Criminal Record Clearance. 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: Obtain a California clearance or a criminal record exemption as required by the Department.This requirement is not being met as evidence by: LPA observed T1 to be residing within the garage which has been converted into living quarters.
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Both T1 and T2 must leave immediately to obtain a criminal record clearance. T1 and T2 are not to return until clearance is received. Licensee is to provide proof of T1 and T2 requesting fingerprint clearance and provide LPA a signed/dated statement specifying the Licensee understands that all individuals working, residing, or volunteering in a licensed facility
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After speaking with the licensee, it was disclosed that another individual T2 resides within the facility but is not present during day care hours. Neither T1 nor T2 have the proper criminal record clearance. This poses an immediate risk to the health and safety of children in care.
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obtain a clearance prior to presence within the home.

**civil penalty issued on today's date**

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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:Wynn Norona
LICENSING EVALUATOR NAME:Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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