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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700420
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:29:53 PM

Document Has Been Signed on 10/20/2023 02:29 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:AGARWAL, SURBHIFACILITY NUMBER:
015700420
ADMINISTRATOR:AGARWAL, SURBHIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 764-7978
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
10/20/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Surbhi AgarwalTIME COMPLETED:
02:40 PM
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On 10/20/2023 at 1:50PM Licensing Program Analyst (LPA) Jaleesa Jackson met with Licensee Surbhi Agarwal for the purpose of conducting an Unannounced inspection to view new on-limits and off-limits areas of the home. LPA informed Licensee of the purpose of todays visit and was granted entry into the home. Present for today’s inspection was the Licensee, one fingerprint cleared assistant, four infants, and one preschool aged child.

The licensee recently emailed LPA about making some rooms on limits to expand her day care and therefore required a visit to view and approve the new on-limit areas.

ON LIMITS AREA: Living Room, Kitchen, Dining Area, Day care Hall (living area in the back of the home), Day care Room (Room attached to Day care Hall, Bathroom #1 (attached to day care room), nap room (first room to the right of day care hallway), and Backyard

OFF LIMITS AREA: Two (2) Bedrooms, Bathroom #2, Master Bedroom with attached Full Bathroom and Garage

ISOLATION AREA: Nap room

Off limits rooms are made inaccessible by closed doors and visual supervision. The new on-limits and off-limits as described above are approved as of this day, 10/20/2023. Appeal rights were given to Licensee.

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

Exit interview conducted and report was reviewed with the Licensee Surbhi Agarwal.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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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