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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413958
Report Date: 11/08/2021
Date Signed: 11/15/2021 09:35:53 AM

Document Has Been Signed on 11/15/2021 09:35 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:VEDULA, SIVA LAXMIFACILITY NUMBER:
434413958
ADMINISTRATOR:VEDULA, SIVA LAXMIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 564-0536
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Siva Laxmi and Viswam GullapalliTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Morales met with Licensee, SivaLaxmi Vedula and husband Vismam Gullapall for an unannounced Annual/ Required Inspection. Days and hours of operation are Monday - Friday from 9:30-to 5:30 PM. Adults who reside in the home are the Licensee, and her spouse. All have finger print clearances. Last fire drill was conducted on 9/2021. LPA observed current Children's roster.

During today's visit, LPA observed one child who is three years old taking a nap in the living room.

LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA observed a wood stove fireplace for which the Licensee has a waiver on file. Off limit areas inside Licensee's home: 3 bedrooms and 1 bathroom and attached garage. Off limit areas outside the home: right side yard.

LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. The Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children.

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SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: VEDULA, SIVA LAXMI
FACILITY NUMBER: 434413958
VISIT DATE: 11/08/2021
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. Licensees stated that they do not take care of children who are ill. 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. Licensee have an area where sick children can be isolated from the others until parent pick-up.

Licensee and husband have current Mandated Reporter Certificate. Licensee last Mandated Reporter Certificate expires 11/11/2022 and husband expires on 10/4/2023. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed atwww.mandatedreporterca.com.

Licensee and husband have current CPR and First Aid card. Licensees First Aid/Pediatric expires on 9/2022 and her husband expires on 12/2022

LPA was informed that they don't take care of infants under twelve months of age, however, they do supervise an infant of the age of 18 months. LPA discussed and left a copy of Pin 20-24-CCP, RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT. Discussed that all INFANTS UP TO 12 MONTHS OF AGE MUST HAVE AN INDIVIDUAL INFANT SLEEPING PLAN (LIC9227) OF FILE, WHICH WILL DOCUMENT THE INFANTS SLEEPING HABITS, USUAL SLEEPING ENVIRONMENT, AND THE INFANT ROLLING ABILITIES. PROVIDERS MUST CONDUCT CHECKS EVERY 15 MINUTES ON SLEEPING INFANTS (UP TO AGE 2 ).

SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: VEDULA, SIVA LAXMI
FACILITY NUMBER: 434413958
VISIT DATE: 11/08/2021
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A conducted an exit interview with the Licensee and advised her that no deficiencies issued during today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.


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
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC809 (FAS) - (06/04)
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