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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422774
Report Date: 02/25/2022
Date Signed: 02/25/2022 12:27:07 PM

Document Has Been Signed on 02/25/2022 12:27 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:KUPPUSWAMY, HEMA MUTHULAKSHMIFACILITY NUMBER:
013422774
ADMINISTRATOR:KUPPUSWAMY, HEMA MUTHULAKSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(972) 979-5658
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Hema KuppuswamyTIME COMPLETED:
12:50 PM
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On February 25, 2022 at approximately 8:20am Licensing Program Analyst (LPA) Russ Haderer met with licensee Hema Kuppuswamy for the purpose of conducting an unannounced annual inspection for health and safety. Living in the home is the licensee, her TB test and fingerprint cleared husband and their two children. Present for today’s inspection was licensee and her fingerprint and TB cleared husband, one assistants and 9 children in care (2 infant; 4 two-year olds, 1 three-year old; 2 four-year old). The hours of operation are Monday-Friday, 8:00am to 6:00pm.

The facility is a single-family home with 4 bedrooms and 2 bathrooms, a living room (day care area), dining room, kitchen, attached 2-car garage, back and side yards. Access to the day care area is through the side gate and to the back sliding door. Toxins, medicines, and hazardous items were inaccessible during today's inspection.

On-limit-areas include: The family room (day care area), dining room, hallway leading to the house bathroom, house bathroom at the end of the hall, back yard patio and grass area.



Off-limit-areas include: All four bedrooms, kitchen, master bathroom, attached 2-car garage, east side of backyard. All off limit areas are inaccessible by closed and/or locked doors, child gates and visual supervision.

There were ample age appropriate toys that were observed to be safe and in good condition. The home and the day care area and rooms are neat and clean, with heating and ventilation for safety and comfort.

During the inspection LPA observed cabinet doors under the children's bathroom sink were not secured with child-proof latches and contained items labeled "keep out of the reach of children." This is a Type B deficiency, see LIC809D for deficiency.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KUPPUSWAMY, HEMA MUTHULAKSHMI
FACILITY NUMBER: 013422774
VISIT DATE: 02/25/2022
NARRATIVE
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There is a 2A10BC fire extinguisher located on the garage (the needle on the gauge was well below the safe “fully charged” range). This is a Type A deficiency. See LIC 809D for deficiency. The facility has a dual smoke and carbon monoxide detector, (tested and working). Per licensee, there are no firearms in the home. The licensee conducts and documents Fire/Disaster Drills at least twice a year, and the log indicates a drill was conducted 1/25/2022. Licensing documents are posted and visible for public review.

At 10:00am children's files were reviewed. The facility roster was reviewed, and a copy obtained. Two children’s files were missing the consent for medical treatment forms. This is a Type B Deficiency, see LIC809D. Licensee monitor’s sleeping infants but did not maintain Infant sleep logs. This is a Type B Deficiency, see LIC809D.

The licensee’s Pediatric CPR/First Aid certificate is current and expires 8/14/2023. Mandated reporter training was completed on 6-15-2021. Assistant’s files did not contain the Mandated Reporter certificate, assistant confirmed she has not taken this course. This is a Type B deficiency, see LIC809D. Licensee, helpers and all adults living in the home are in compliance with immunization law which pertains to day care providers.

LPA reminded the licensee of the following: Mandated Reporter training is to be renewed every two years, CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.



The licensee owns the property but does not carry liability insurance. Signed form LIC282 acknowledging there is no liability insurance located in each child’s file.

Incidental Medical Services (IMS) policy was discussed. 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
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
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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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KUPPUSWAMY, HEMA MUTHULAKSHMI
FACILITY NUMBER: 013422774
VISIT DATE: 02/25/2022
NARRATIVE
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] 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.

There was one Type A deficiency and 4 Type B deficiencies issued during today’s inspection. See LIC809Ds: This report will remain on file for 3 years.

A review of operating safely during the Covid-19 pandemic (RAST) was conducted.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Hema Kuppuswamy.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2022 12:27 PM - It Cannot Be Edited


Created By: Russell Haderer On 02/25/2022 at 11:48 AM
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: KUPPUSWAMY, HEMA MUTHULAKSHMI
FACILITY NUMBER: 013422774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the fire extinguisher was not fully charged (needle was well below the safe “fully charged” range) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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Licensee's husband immediately purchased a new fully charged 2A10BC fire extinguisher. New extinguisher now in place.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2022 12:27 PM - It Cannot Be Edited


Created By: Russell Haderer On 02/25/2022 at 11:48 AM
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: KUPPUSWAMY, HEMA MUTHULAKSHMI
FACILITY NUMBER: 013422774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that cabinet doors under the children's bathroom sink were not secured with child-proof latches and contained items labeled "keep out of the reach of children" which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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Licensee located child-proof latch and installed it on the cabinet door. Licensee advised that in lieu of a child-proof latch she may also remove any products potentially harmful to children.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that no infant safe sleep logs are currently maintained which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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LPA left a copy of a sample sleep log for the licensee to begin using immediately and going forward.
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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/25/2022 12:27 PM - It Cannot Be Edited


Created By: Russell Haderer On 02/25/2022 at 11:48 AM
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: KUPPUSWAMY, HEMA MUTHULAKSHMI
FACILITY NUMBER: 013422774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that her assistant has not completed Mandated Reporter training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
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Assistant will complete the free Mandated Reporter training and submit a certificate as proof of completion.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two of the children's files did nit contain the LIC627 Consent for Medical Treatment Form signed by any authorized parent or representative which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2022
Plan of Correction
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Licensee will obtain signed and dated forms from the parents for Consent for Medical Treatment and submit photos as proof of completion.
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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022


LIC809 (FAS) - (06/04)
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