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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422944
Report Date: 06/25/2025
Date Signed: 07/03/2025 09:47:52 AM

Document Has Been Signed on 07/03/2025 09:47 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:AGARWAL, SHRUTIFACILITY NUMBER:
013422944
ADMINISTRATOR/
DIRECTOR:		SHRUTI AGARWALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(518) 836-8473
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
06/25/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Shruti AgarwalTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On June 25, 2025, Licensing Program Analyst (LPA) Simerjit Kaur met with licensee Shruti Agarwal, for the purpose of an Unannounced Case Management Inspection. Present during the inspection, fingerprint clear and associated Rahul Agarwal, Radha Agarwal, and Shikha Agarwal. The facility self reported an unusually incident to licensing on June 18, 2025, and a copy of the Unusual Incident Report (UIR) was reviewed by LPA Kaur. Present during today's inspection were 2 infant age children and 2 staff members. The purpose of the visit was to follow up on an unusual incident reports received and submitted by the facility regarding a child had fracture femur. Licensee is unable to determine the cause of the injury.

On June 18, 2025, licensee reported an Unusual Incident to the Regional Office (RO). The summary of the unusual incident is as follows: On 6/17/25 at approximately 3:30pm child was playing with a toy truck and started crying. Child cried off and on for about 20 minutes. Assistants told licensee that child was crying because the toy truck was taken away. Licensee was in the main house when child began to cry. Licensee heard child crying and asked assistants about it. Assistants stated that child was comforted. Assistant rubbed child's back when he started crying. Licensee observed child playing at 3:45pm at that time child was sitting and playing with a toy. Child was not crying. Child was picked up at approximately 4:15pm. When child left he wasn't crying and didn't seem to be in pain. Parent text licensee at 8:55pm asking if something happened in care and if licensee noticed anything strange with child's walk as child had been crying at home and not wanting to walk. Parent also reported that child was lethargic. Child has a medical appointment 6/18/25 at 11:45am. Child is not in care today. Licensee stated that camera that records in the home was not working.


LPA Kaur conducted interviews of staff. There are no deficiencies being cited today. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with licensee Shruti Agarwal.
NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Simerjit Kaur
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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