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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700197
Report Date: 12/07/2021
Date Signed: 12/07/2021 09:20:11 AM

Document Has Been Signed on 12/07/2021 09:20 AM - 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:SHIVASUBRAMANI, UMADEVIFACILITY NUMBER:
015700197
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Umadevi Shivasubramani- LicenseeTIME COMPLETED:
09:25 AM
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On 12/7/21 at 8:23am, Licensing Program Analyst Briana Plumboy, met with licensee Umadevi Shivasubramani for an UNANNOUNCED ANNUAL INSPECTION. Present for this visit was licensees fingerprint clear and associated husband Pandiarajan Subramani and infant son. The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday through Friday from 8:00am until 6:00pm.

The home is a single story home. The home consists of 2 bedrooms, a master bedroom with a master bathroom, a hallway bathroom, a living room, a kitchen, and garage. The home is neat and clean with heating and ventilation for safety and comfort. The OFF LIMIT AREAS are the master bedroom with master bathroom, the bedroom located at the end of the hallway on the right, the kitchen, and the garage which will be inaccessible by closed and/or locked doors and visual supervision. There are child safety gates located on both entrances to the kitchen. The ON LIMIT AREAS are the living room, first bedroom on the right side of the hallway, the hallway bathroom, and the cement area in the backyard. The ISOLATION AREA will be the first bedroom on the right side of the hallway. Outdoor play area will be on the cement in the fenced backyard. There are toys and learning materials. There are no pools, hot tubs or any other bodies of water on the premises. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.

The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The licensee’s Health and Safety training is completed and CPR and First Aid certificate is current and expires 1/9/23. The licensee completed and received a certificate in mandated reporter training on 12/17/20. The licensee is in compliance with new immunization law which pertains to day care providers. There are no wall heaters or fireplaces in the home during today's inspection. The home has centralized heating. Per licensee, there are no firearms in the home. The licensee has not conducted or documented a fire and disaster drill due to her not having children in care. All REQUIRED forms are posted and visible for public review.
See 809-C for continuance
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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: SHIVASUBRAMANI, UMADEVI
FACILITY NUMBER: 015700197
VISIT DATE: 12/07/2021
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Incidental Medical Services (IMS) policy was discussed. 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

Licensee was encouraged to frequently visit our website at ccld.ca.gov for licensing regulations and updates.

Licensee is reminded that ALL assistants, volunteers, and staff, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov



LPA discussed the safe sleep regulations with licensee Umadevi Shivasubramani 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 Umadevi Shivasubramani 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.

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

No deficiencies cited during today's inspection. Appeal rights provided and discussed. Exit interview conducted and report was reviewed with licensee Umadevi Shivasubramani.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC809 (FAS) - (06/04)
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