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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500381
Report Date: 05/24/2021
Date Signed: 05/24/2021 03:09:20 PM

Document Has Been Signed on 05/24/2021 03:09 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:CHIGULLAPALLI, ALIVENIFACILITY NUMBER:
394500381
ADMINISTRATOR:CHIGULLAPALLI, ALIVENIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 404-9677
CITY:TRACYSTATE: CAZIP CODE:
95377
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Aliveni ChigullapalliTIME COMPLETED:
02:45 PM
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NOTE: Due to Covid-19 and DPH guidelines on physical distancing, a Tele-visit via FaceTime was conducted. On Monday, May 24, 2021, at 01:12 PM, Licensing Program Analyst (LPA) Elvira Sierra conducted a Prelicensing visit for the purpose of change of location. Applicant was previously license under facility # 073407217. LPA explained about obtaining $300,000 liability insurance. Facility hours of operation will be M-F from 08:00 AM to 06:00 PM. All individuals residing in the home have obtained a criminal record clearance. Applicant's husband, son and granddaughter were present at the time of the visit. Applicant understands children under the age of 10 will count on her capacity when present. Fire clearance was granted for a capacity of 14 children and approved on 05/20/21.

At 01:20 PM, with the help of the Applicant, a health and safety inspection was conducted and the following was observed. Home is a 4 bedrooms and 3 1/2 bathroom 2 story home. The Off-limits areas include; Entire upstairs, all bedrooms on the first floor, Den (under the stairs), Laundry/Pantry room, Front porch/driveway, and Garage. Applicant acknowledged that children may never enter these off-limit areas. The home is equipped with at least one working carbon monoxide and a smoke detector. LPA observed a fully charged fire extinguisher that meet minimum size requirements. Stairs leading to the second floor are properly barricaded. Applicant was advised that child proof locks must be installed in some kitchen cabinets where chemicals and cleaning supplies are stored. Also sharp utensils or knives must be inaccessible to children. Per Applicant medication will be lock and kept in the pantry inaccessible to the children. Applicant stated that napping equipment will be provided by parents (cribs and sleeping cots). Per Applicant, there are no weapons or bodies of water on the premises. Applicant stated that the water fountain in the backyard will always be filled with stones and no water. Applicant was advised that prior to making alterations or additions to the home or grounds, the applicant shall notify the Department of the proposed changes.
Report continues on page 809C----
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2021
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: CHIGULLAPALLI, ALIVENI
FACILITY NUMBER: 394500381
VISIT DATE: 05/24/2021
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Applicant requested to inspect the second floor on the next inspection. Applicant understands that in unfenced area’s 100% supervision of children is required. Proof of control of property was provided. Applicant has a current CPR that expires on 05/10/23. Mandated Reporter Training expires on 05/17/2023, applicant understands that the training must be updated every 2 years.

*LPA discussed guidance and practices regarding social and physical distancing for providers to prevent exposure to COVID-19 while providing care for children. COVID-19 Posting documents and the use of Personal Protective Equipment during COVID-19 Outbreak guidance*.

Prior to license approval, facility needs to complete the following:

-COVID-19 posters must be displayed at the entry of the home with the parents rights poster and emergency disaster.


-Child proof locks must be installed on the off limits bedrooms downstairs and in the Laundry/Pantry room.
- Latches are required for cabinets in the kitchen and in the bathrooms that are used for storing of toxins.
-Need to installed stove covers
-Must create a sanitation station at the entrance of the home with a thermometer.

LPA provided and discussed the Safe Sleep in Child Care and Effects of Lead Exposure brochures. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so applicant can request to be added to the distribution list to receive Quarterly Updates.

Facility evaluation report was emailed to Applicant and an email verification of receipt of report will be used in lieu of a signature on this report. Second inspection will be necessary to verify the corrections.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
LIC809 (FAS) - (06/04)
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