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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700049
Report Date: 11/10/2021
Date Signed: 11/10/2021 02:04:36 PM

Document Has Been Signed on 11/10/2021 02:04 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:NALEM, KOMURAVVAFACILITY NUMBER:
015700049
ADMINISTRATOR:NALEM, KOMURAVVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 458-6580
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Komuravva NalemTIME COMPLETED:
02:30 PM
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On 11/10/2021 approximately at 12:05PM Licensing Program Analyst (LPA) Kelly Phan arrived at for an unannounced required inspection, and met with Licensee Komuravva Nalem. Present for this inspection was 4 infants and 4 preschoolers along with associated and fingerprinted helper, Nishi Shelopal. Also residing in the home is the licensee's fingerprinted and associated husband, Ramesh Nalem. Per licensee she has two children who are between 10 1/2 and 13 years old who goes to school until 3PM. The home was toured with the licensee and her husband to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 8:00am to 6:00pm.

ON LIMITS: bedroom #1 (for napping and playing area), bathroom #1, full backyard, bedroom #2 (for napping infants), living room space
OFF LIMITS: master bedroom, garage, and kitchen . Off limit areas are inaccessible by closed and/or locked doors, gate, and visual supervision.

The home is single story, which is neat and clean, with heating and ventilation for safety and comfort. A child safety gate is in placed to prevent children from entering kitchen and has closed/locked doors in off-limited areas. There were ample age appropriate toys that were observed to be safe and in good condition. Toxins, medicines, and hazardous items were inaccessible during today's inspection. There is a fully charged 3A40BC fire extinguisher, carbon monoxide and smoke detector that meets State standards. The home has an electric fireplace that is blocked off by a glass mirror. Per licensee, there are no firearms or pets or any bodies of water in the home. The licensee conducts and documents fire drill log indicates a drill was conducted 5/20/21. All required licensing documents are posted and visible for public review. A notice of parent's notification of rights were given to licensee to post as it was missing from her facility board. At 1:30pm, six children files were reviewed and found to be complete. The facility roster was reviewed, and a copy obtained. The licensee is in ratio today. Licensee has proof of the required immunizations.
SEE LIC 809 C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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: NALEM, KOMURAVVA
FACILITY NUMBER: 015700049
VISIT DATE: 11/10/2021
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Required mandated reporter training that is completed as of 11/21/2019. Licensee and her husband will complete required training and will send a copy of certificate to LPA. CPR and First Aid training are also updated as of 03/27/2021 that would expired on 3/27/2022. The backyard was assessed and is free of hazardous items as right side of the backyard has a secure locked door to prevent children not entering/exiting the facility. LPA also reminded licensee to have a secure screen for the wall heater to prevent harm to the children, per licensee the wall heater is not being used during work hours. LPA was informed that the insolation area for children would be one of the two bedrooms, in place if a child becomes ill at their care.

Exit interview conducted. Appeal rights and site visit was given to licensee to post for 30 days.
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Facility Representative was reminded that all adults 18 and over, 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 Child Care Center. 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.

Facility Representative was reminded that California Law requires licensed Child Care Centers 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 electronic mail. LPA informed the Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email [email protected] to be included in the Child Care Quarterly Updates distribution list. The Facility Representative 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.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC809 (FAS) - (06/04)
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