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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420796
Report Date: 11/18/2021
Date Signed: 11/18/2021 02:53:13 PM

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:SULTANI, SHARARAFACILITY NUMBER:
013420796
ADMINISTRATOR:SULTANI, SHARARAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 386-5727
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:14CENSUS: 5DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Sharara SultaniTIME COMPLETED:
03:05 PM
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On 11/18/2021 at 12:10pm Licensing Program Analysts (LPAs) Jaylena Miller and Christina Uribe, met with licensee Sharara Sultani for an UNANNOUNCED ANNUAL REQUIRED INSPECTION. Present for the inspection were 5 daycare children, and the licensee is within ratio today. Upon arrival LPA provided licensee a copy of form LIC 126. The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday-Friday 8:00am-5:30pm

The home is a single home with 3 bedrooms including a master bedroom with master bathroom, one bathroom, living room, family room, kitchen, dining area, laundry room, garage and back yard. LPAs observed the home to be neat and clean with central heating and ventilation for safety and comfort.

The OFF-LIMIT AREAS are the master bedroom and bathroom, laundry room and garage, and will be inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS are the two additional bedrooms, hallway bathroom, kitchen, dining area, living room and family room that is used as the main daycare area. The designated isolation area will be the dining area. The backyard will be a designated outdoor play area that is fully fenced. The outdoor area has age appropriate toys and furnishings that LPAs observed to be clean and free from defects and dangerous conditions.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged fire extinguisher 2A-10-BC, working smoke detector, carbon monoxide, telephone and fully stocked first aid kit. There are no pools, hot tubes or any other bodies of water present at the time of the inspection. Per licensee, there are no firearms on the premises.

The licensee completed the Health and Safety training, CPR/First Aid expired on 5/23/2021 as a result a Type B citation is being cited today, please see LIC 809-D for deficiency cited. The licensee is in complaint with the immunization laws and has completed the mandated reporter training on 11/9/2021.

Please see LIC 809-C for continuance

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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: SULTANI, SHARARA
FACILITY NUMBER: 013420796
VISIT DATE: 11/18/2021
NARRATIVE
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The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 11/2/2021. All required forms are posted and visible for public review.

At 12:30pm LPA Uribe reviewed 5 children’s files, facility file and documented on LIC 857. Upon review of children's files deficiencies were cited, please see LIC 809-D for deficiencies cited. There is a current roster available for review and copy obtained. Staff interview also conducted and documented.



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

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 inspectionprocess@dss.ca.gov. 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/process.

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.

LPA discussed the safe sleep regulations with licensee 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.

Please see LIC 809-C for continuance

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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: SULTANI, SHARARA
FACILITY NUMBER: 013420796
VISIT DATE: 11/18/2021
NARRATIVE
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Licensee was reminded of the responsibility as a mandated reporter and the training's must be done once every two years as well as CPR/First Aid needs to be renewed every two years and must be EMSA approved. LPA also encouraged licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, as well as all forms can be downloaded. For licensing updates and Quarterly Child Care Distribution email, email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list.

Effective August 1, 2003 California Law requires Child Care licensees 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 to the regional office by phone and the written report, LIC 624 within 7 business days.

After a complete inspection of the facility, the attached deficiencies were cited, Please see LIC 809-Ds for deficiencies. Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be posted in the facility and given to each existing parent by the end of today or next day child is in care. This report also must be provided to the parent of children who are enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Sharara Sultani.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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: SULTANI, SHARARA
FACILITY NUMBER: 013420796
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 5 children files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2021
Plan of Correction
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Have parents sign correct LIC 627 for C1, C3, C4 and C5
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: SULTANI, SHARARA
FACILITY NUMBER: 013420796
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above for licensee which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2021
Plan of Correction
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licensee must complete or sign up for CPR/First Aide certification (EMSA approved)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

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 2 out of 5 childrens files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2021
Plan of Correction
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licensee must have parents of C1 and C3 complete and sign the LIC 28 form and place in file
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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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