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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408683
Report Date: 06/18/2021
Date Signed: 06/18/2021 09:53:51 AM

Document Has Been Signed on 06/18/2021 09:53 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:AGARWAL, KANIKAFACILITY NUMBER:
073408683
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/18/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kanika AgarwalTIME COMPLETED:
09:55 AM
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At 9:00am on 6/18/2021 Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Kanika Agarwal to conduct a Case Management visit for a Capacity Increase. Present during the inspection was Licensee Kanika Agarwal and her fingerprint cleared husband Atul Kumar. The facility currently plans to operate Monday – Friday 7:00am – 6:30pm. The Licensee’s home was then toured for the health and safety inspection.

ON LIMITS AREA: Family Room, Living Room and Downstairs Bathroom


OFF LIMITS AREA: Kitchen, Guest Room, Backyard, Garage and entire 2nd floor
ISOLATION AREA: Living Room

The home has gained a fire clearance on 6/10/2021 from the San Ramon Valley Fire Protection Department.

The inside of the home is observed to be neat, clean with ample age appropriate materials for the children that are safe and clean. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas to the children. Licensee has stated that there are no firearms or pets in the home.

The home has one fully charged 3A40BC fire extinguisher, located in the hallway by the stairs.There is a pull station alarm in the entry way, and a working smoke detector/carbon monoxide combination in the living room, family room and in the hallway in front of the bathroom.

The Licensee’s Health and Safety training has been completed and CPR and First Aid will be renewed on 7/11/2021. The home is equipped with central heating and air for proper ventilation. Licensee provided proof of immunization for pertussis, measles, and the flu shot.

LPA provided COVID-19 Self-Assessment Guide and all answers were discussed. LPA provided technical assistance regarding all COVID-19 policies and procedures. Cont on 809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2021
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: AGARWAL, KANIKA
FACILITY NUMBER: 073408683
VISIT DATE: 06/18/2021
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Licensee was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed the Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed as well. Licensee was reminded that when any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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 is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.

This home has been approved for the Capacity Increase on 6/18/2021.

This report was read and given to the Licensee for a signature. This report shall remain on file for 3 years. Appeal Rights were provided and exit interview conducted.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC809 (FAS) - (06/04)
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