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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423429
Report Date: 02/23/2022
Date Signed: 02/23/2022 01:04:58 PM

Document Has Been Signed on 02/23/2022 01:04 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:RAJPUT, KOMALFACILITY NUMBER:
013423429
ADMINISTRATOR:KOMAL RAJPUTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 728-0307
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Komal RajputTIME COMPLETED:
01:12 PM
NARRATIVE
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On February 10, 2021 at approximately 8:20am Licensing Program Analyst (LPA) Russ Haderer met with licensee Komal Rajput for the purpose of conducting an unannounced annual inspection for health and safety. Living in the home is the licensee, her TB test and fingerprint cleared husband and her visiting mother. Present for today’s inspection was licensee and her fingerprint and TB cleared husband, licensee’s mother, two assistants and 10 children in care (1 infant; 5 two-year old, 4 three-year old). The hours of operation are Monday-Friday, 8:00am to 5:30pm.

Licensee advised LPA the facility will be closing as they have purchased a new home in Daly City. The last day of operation will be March 31, 2022.

The facility is a single-family home with 4 bedrooms and 2 bathrooms, a living room, dining room, family room, kitchen, attached 2-car garage, back and side yards. Access to the day care area is through the front door. Toxins, medicines, and hazardous items were inaccessible during today's inspection.

On-limit-areas include: The family room (day care area), dining room, house bathroom, first bedroom on the right side of the hall for napping, back yard patio and grass area.



Off-limit-areas include: Three bedrooms, master bathroom, kitchen, detached 2-car garage and side yards of the home. All off limit areas are inaccessible by closed and/or locked doors, child gates and visual supervision.

There were ample age appropriate toys that were observed to be safe and in good condition. The home and the day care area and rooms are neat and clean, with heating and ventilation for safety and comfort. LPA did not observe any hazardous materials, or toxins accessible to children on the premises during the inspection.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: RAJPUT, KOMAL
FACILITY NUMBER: 013423429
VISIT DATE: 02/23/2022
NARRATIVE
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There is a 2A10BC fire extinguisher located on the kitchen counter (the needle on the gage is just barely into the red area that indicates “empty”). This is a Type A deficiency. See LIC 809D for deficiency. The facility has a dual smoke and carbon monoxide detector, and an additional stand-alone carbon monoxide detector (tested and working). Per licensee, there are no firearms in the home. The licensee conducts and documents Fire/Disaster Drills at least twice a year, and the log indicates a drill was conducted 2/18/2022. Licensing documents are posted and visible for public review, however PUB269 Ca Child Passenger Safety Law poster was missing. Licensee distributed this poster to all parents, LPA provided a new copy to post on the wall.

At 10:45am children's files were reviewed. The facility roster was reviewed, and a copy obtained. Two files were missing the signed Parent’s Rights form LIC995, two other child’s files had unsigned consent for medical treatment forms. Licensee did not maintain the required Individual Infant Sleep Plan (signed by parents) for one 8-month old infant. Licensee did not maintain Infant sleep logs. These are Type B deficiencies, see LIC 809D for details.

The licensee’s Pediatric CPR/First Aid certificate is current and expires 8/14/2023. Mandated reporter training was completed on 6-8-2021. Licensee, helpers and all adults living in the home are in compliance with immunization law which pertains to day care providers.

LPA reminded the licensee of the following: Mandated Reporter training is to be renewed every two years, CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.



The licensee rents the property but does not carry liability insurance. Signed form LIC282 acknowledging there is no liability insurance located in each child’s file.

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
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
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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: RAJPUT, KOMAL
FACILITY NUMBER: 013423429
VISIT DATE: 02/23/2022
NARRATIVE
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to [email protected]. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

LPA discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

There was one Type A deficiency and 4 Type B deficiencies issued during today’s inspection. See LIC809Ds: This report will remain on file for 3 years.

A review of operating safely during the Covid-19 pandemic (RAST) was conducted.



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

Exit interview conducted and report was reviewed with the licensee Komal Rajput.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 02/23/2022 01:04 PM - It Cannot Be Edited


Created By: Russell Haderer On 02/23/2022 at 12:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: RAJPUT, KOMAL
FACILITY NUMBER: 013423429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in two of the children's files contained the LIC627 Consent for Medical Treatment Form, however, they were not signed by any authorized parent or representative
which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2022
Plan of Correction
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Licensee will obtain required signatures on the forms.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/23/2022 01:04 PM - It Cannot Be Edited


Created By: Russell Haderer On 02/23/2022 at 12:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: RAJPUT, KOMAL
FACILITY NUMBER: 013423429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two children's files were missing the signed LIC995 Parent's Rights form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2022
Plan of Correction
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Licensee will obtain signed forms from a parent or authorized representative.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 02/23/2022 01:04 PM - It Cannot Be Edited


Created By: Russell Haderer On 02/23/2022 at 12:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: RAJPUT, KOMAL
FACILITY NUMBER: 013423429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that for a 10-month old infant, there was no Individual Infant Sleeping Plan (LIC9227) which poses a potential health, safety or personal rights risk to persons in care..
POC Due Date: 02/24/2022
Plan of Correction
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Licensee will have parents fill out and sign Individual Infant Sleeping Plans (LIC9227) for all infants 12 months or younger from now on and going forward.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that no infant sleep logs have been maintained which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2022
Plan of Correction
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Licensee will begin maintaining infant sleep logs for all infants up to 24 months.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/23/2022 01:04 PM - It Cannot Be Edited


Created By: Russell Haderer On 02/23/2022 at 12:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: RAJPUT, KOMAL
FACILITY NUMBER: 013423429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(1)
102417 Operation of a Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:
(1) Fireplaces and open-face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the fire extinguisher was not fully charged (needle was out of the safe green area and reading into the red area below the safe “fully charged” range) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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Licensee will re-charge existing unit or purchase a new fire extinguisher.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022


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