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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421011
Report Date: 02/16/2023
Date Signed: 02/16/2023 11:07:36 AM


Document Has Been Signed on 02/16/2023 11:07 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:JAVED, AYESHAFACILITY NUMBER:
013421011
ADMINISTRATOR:JAVED, AYESHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 524-0351
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:14CENSUS: 10DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Licensee, Ayesha JavedTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jyoti Saini met with Licensee,Ayesha Javed for an unannounced Annual Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during this inspection was Licensee, and her husband supervising 2 infants and 8 preschoolers. Licensee lives in the house with her husband and two children. The home is a two-story home with 4 bedrooms, 3 bathrooms, living room, family room, kitchen, dining room, laundry room, garage and back yard. The hours of operation are 8:00am to 6:00pm Monday -Friday.

On limit areas : are the family room, kitchen, dining room and living room (main day care area)



Off-limit-areas: the entire second floor and garage. All off limit areas are inaccessible by closed and/or locked doors and visual supervision.
LPA inspected the house for health and safety hazards. Daycare Area is clean, orderly, and equipped with age appropriate toys. Home has a working telephone, a working smoke and carbon monoxide detector, and a fire extinguisher that meets the minimum requirements. There are no bodies of water in the day care area. There is a fireplace in the daycare room which is not in use during an operational hour. There is a safety gate at the base of the stairs to prevent access to the second floor. The licensee conducts and documents Fire/Disaster Drills at least twice a year, and the log indicates a drill was conducted 11/2022. There are child size tables and chairs for snack and activities. There are ample of age appropriate toys that appear to be safe and in good condition. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. The napping room had cots in good condition and each child have their separate blankets. Licensee states there are no guns or weapons of any kind in the home. There are no pets in the home. The outdoor play area is fenced and is free from defects and dangerous conditions. Licensee and husband have valid CPR. Licensee provides daily snacks and meals. Discipline policy is redirection. LPA reviewed children’s files. LPA discussed safe sleep guidelines and advised to document infant's sleep checks. All required postings are properly posted.
see next page...
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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: JAVED, AYESHA
FACILITY NUMBER: 013421011
VISIT DATE: 02/16/2023
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During Inspection, 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.



Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com

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/inspection-process.

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

The attached type B deficiency is cited today.

Exit interview conducted and report was reviewed with the licensee Aysha Javed.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 02/16/2023 11:07 AM - It Cannot Be Edited

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: JAVED, AYESHA
FACILITY NUMBER: 013421011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 10 out of 10 children's files did not contain the signed acknowledgement of No Liability Insurance forms which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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Licensee shall obtain signed LIC282 forms from each parent and place them in the children's files.
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: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3