013422774-1-12-2023-52-CC-RHAR-CMZVQ4-20230112153742

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013422774
Report Date: 01/12/2023
Date Signed: 01/12/2023 03:37:49 PM

Document Has Been Signed on 01/12/2023 03:37 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 MUTHULAKSHMI		FACILITY NUMBER:	013422774
ADMINISTRATOR:	KUPPUSWAMY, HEMA MUTHULAKS		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(972) 979-5658
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 11	CENSUS: 10	DATE:	01/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Hema Kuppuswamy		TIME COMPLETED:	03:50 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

On January 12, 2023 at approximately 12:50pm Licensing Program Analyst (LPA) Russ Haderer arrived unannounced for the purpose of conducting an annual inspection for health and safety. Present for today’s inspection was the licensee Hema Kuppuswamy and fingerprint and TB cleared helper Juvily Ancheta and 10 children in care (2 infants; 5 two-years old; 2 three-years old; 1 four-years 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 has a screened fireplace and also blocked); 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.

There is a fully charged 2A10BC fire extinguisher located in the daycare room. 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 twice per year, however, the log indicates a drill was last conducted on June 1, 2022 which is past the due date of December 1, 2022 see LIC809D for deficiency. All licensing documents are posted and visible for public review.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
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)

Page: 1 of 4

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: 01/12/2023

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

Children's files were reviewed. The facility roster was reviewed, and a copy obtained. All files were complete and in good order.

The licensee’s Pediatric CPR/First Aid certificate is current and expires 8/14/2023. Mandated reporter training was completed on 6-15-2021 (licensee) and 3-02-2022 (assistant). Licensee, helpers 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 rents 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

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.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
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

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/12/2023 03:37 PM - It Cannot Be Edited

Created By: Russell Haderer On 01/12/2023 at 03:12 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: KUPPUSWAMY, HEMA MUTHULAKSHMI	FACILITY NUMBER: 013422774
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that the log indicates a drill was last completed on June 1, 2022 which is more than 6 months time which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Licensee will conduct a drill and provide a copy of the log to LPA as proof of completion. Licensee will conduct drills at least once every 6 months and log them.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 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)

Page: 3 of 4

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: 01/12/2023

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

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 B deficiency issued during today’s inspection (disaster drill not conducted). See LIC809D for details:

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: 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

LIC809 (FAS) - (06/04)

Page: 4 of 4