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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625196
Report Date: 12/11/2024
Date Signed: 12/11/2024 02:57:07 PM

Document Has Been Signed on 12/11/2024 02:57 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KOPPULA, VIJAYA LAKSHMIFACILITY NUMBER:
343625196
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
12/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Vijaya Lakshmi KoppulaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Erwina Pascual-Golamco met with Licensee, Vijaya Lakshmi Koppula, to conducted a Plan Of Correction inspection. Purpose of inspection was explained. There was one Type A deficiency cited on 12/03/24:

CCR 102417(g)(5):
102417(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.

Plan of correction was: Licensee will place material/s that will prevent water to fill up the fountain. LPA observed that licensee has placed a tarp on top of the fountain. The tarp is attached by a rope at the back to hold it down and prevent water build up. LPA observed that it is a temporary fix. Licensee stated she will permanently fix the prevention of water build up in the fountain and she has provided the following options:

- place a permanent cover to the fountain that will support the weight of an adult.
- place soil and plants to convert the fountain as a plant box.
- install drain to the fountain.

As of today, 12/11/24, LPA did not observed bodies of water on the premises. Licensee will email and provide LPA the permanent fix of the fountain on January 15, 2025. Licensee will inform LPA if she needs more time. Licensee also asked LPA to place the backyard on off limits area as of today. No deficiencies cited in today's inspection, exit interview was conducted, and Notice of Site visit was provided and shall be posted where visible to parents for 30 days
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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