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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500745
Report Date: 11/22/2022
Date Signed: 11/22/2022 01:50:42 PM

Document Has Been Signed on 11/22/2022 01:50 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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:DUBEY, SHIKHAFACILITY NUMBER:
394500745
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
11/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:licensee, Shikha DubeyTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Lauren Scott and Tobias Lake met with Applicant, Shikha Dubey for the purpose of a prelicensing evaluation. All individuals subject to criminal background review have obtained a criminal record clearance. Applicant's tentative hours are Monday - Friday from 7:00AM to 5:30PM.

A health and safety inspection was conducted inside and out. The two story home has 3 bedrooms and 3 bathrooms. The off-limits area in the home include the garage, family room, dining room, kitchen and entire upstairs. Outdoor play area was toured. At the time of the inspection, the outdoor area is not fully fenced in. This area requires 100% supervision anytime children enter this area. There are no bodies of water on the premises. LPA toured the bedrooms and verified toxic and hazardous items were inaccessible to children in care. Off-limits areas will remain inaccessible to children by door knob covers and baby latches.



Functioning smoke and carbon monoxide detectors were observed in the hallway. LPA observed cleaners stored in the garage, inaccessible to children. 2A10BC fire extinguisher and first aid kit were observed in the kitchen. Applicant stated there are no weapons in the home.

LPA discussed the new Mandated Reporter Training with applicant. Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/. Applicant has a current Mandated Reporter Training Certificate that expires 6/2024. Current pediatric CPR and first aid training was verified and expires 07/2024.


Report continues on 809-C.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: DUBEY, SHIKHA
FACILITY NUMBER: 394500745
VISIT DATE: 11/22/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA 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

This facility evaluation report was reviewed and discussed with the applicant. Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes. LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list. childcareadvocatesprogram@dss.ca.gov

Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction.

Applicant understands that if they want to make any off-limit area an on-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area. Applicant understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to three years.



As of today, Applicant will be approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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