013421458-3-4-2020-52-CC-BPLY-BMDQRL-20200304112407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013421458
Report Date: 03/04/2020
Date Signed: 03/04/2020 11:24:16 AM

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:	SALAYEVA, ARIFA		FACILITY NUMBER:	013421458
ADMINISTRATOR:	SALAYEVA, ARIFA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 477-0939
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	14	CENSUS: 5	DATE:	03/04/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Arifa Salayeva- Licensee		TIME COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/04/20 at 10:04am, Licensing Program Analyst (LPA) Briana Plumboy, met with licensee Arifa Salayeva for an UNANNOUNCED ANNUAL REQUIRED INSPECTION. Present for this visit was licensee's fingerprint clear and associated husband Rahim Salayev, 1 infant, and 4 preschool age children. The home was toured by LPA Plumboy and licensee Arifa Salayeva to conduct a Health and Safety Inspection upon LPA Plumboy's arrival at the facility at 10:04am. The facility currently operates Monday through Friday from 8:00am until 6:00pm. The home is two stories. The ON LIMIT AREAS are the family room, dining room, kitchen, 2 patio rooms, and downstairs bathroom. The OFF LIMIT AREAS are the garage, living room, downstairs bedroom, laundry room, and entire second level of the home. There is a child safety gate located between the family room and patio room. The ISOLATION AREA will be the family room. The BACKYARD play area is fenced. There are toys and learning materials present during today's inspection. There are no pools, hot tubs or any other bodies of water present during the inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that during the inspection there are no toxins or hazardous items accessible. At 10:54am, the licensee provided current day-care insurance to LPA Plumboy. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone (all which were tested and checked during the inspection upon LPA's arrival at the home at 10:04am). The licensee's CPR and First Aid certificate is current and expires 12/12/2021. LPA Plumboy reviewed the licensee's mandated reporter training certificate at 10:29am, and found she completed the course and received a certification of completion on 03/30/19. The licensee is in See 809-C for continuance

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020

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: SALAYEVA, ARIFA	FACILITY NUMBER: 013421458
	VISIT DATE: 03/04/2020

NARRATIVE

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compliance with the immunization law. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 12/05/19.
At 10:39am, LPA Plumboy began a file review of 5 children files. At 10:50am, the facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review.

Individual 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

LPA Plumboy provided a copy of Safe Sleep in Child Care brochure, a handout "What Does A Safe Sleep Environment Look Like?," and PIN 19-06-CCP to the licensee
LPA Plumboy provided licensee with a copy of the CDSS handout on Effects of Lead Exposure

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility. Licensee was reminded of Departments inspection authority, with our without any notice.

California Law requires Family Child Care Home 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 by phone, fax, or electronic mail. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.

See 809-C for continuance

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020

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: SALAYEVA, ARIFA	FACILITY NUMBER: 013421458
	VISIT DATE: 03/04/2020

NARRATIVE

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The licensee was also reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, 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

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list

There are no deficiencies cited. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020

LIC809 (FAS) - (06/04)

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