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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422085
Report Date: 08/03/2023
Date Signed: 08/03/2023 04:12:29 PM


Document Has Been Signed on 08/03/2023 04:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:AYCHILUHIM, HIRUTFACILITY NUMBER:
013422085
ADMINISTRATOR:AYCHILUHIM, HIRUTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 228-8367
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:14CENSUS: DATE:
08/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Hirut AychiluhimTIME COMPLETED:
04:30 PM
NARRATIVE
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 Licensing Program Analysts (LPAs) Andrew Elliot met with Licensee Hirut Jifar Aychilulhim for an unannounced Annual Random Inspection on August 3rd, 2023 at 1:50 PM. LPA disclosed the purpose of the inspection and was granted entry into the facility by the staff. At the time of the inspection, the Licensee was present in the facility along with 2 infants and 3 preschool aged children. The licensee’s 17-year-old daughter was home, but on the second story of the property, which is not part of the day care facility. Licensee is within capacity limits. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 7:00AM until 5:30 PM, MONDAY-FRIDAY. This is two story house consists, 6 bedrooms and 3 bathrooms, 2 kitchens, Garage and backyard. Entry into the childcare area is through the side of the home, through the gate.
On-limit-areas are : Downstairs level: Living/Play room, 3 bedrooms, 1 bathroom and back yard.
Off Limit areas are: Entire upstairs, Downstairs kitchen, and garage. Isolation area: is one of the bedrooms. that is on limits There are no pools, hot tubs or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children. Per licensee, there are no firearms in the home. The home has a fully charged (3A40BC) fire extinguisher, working smoke detector, working carbon monoxide detector, working.
telephone.

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SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Andrew ElliottTELEPHONE: (510) 363-5635
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: AYCHILUHIM, HIRUT
FACILITY NUMBER: 013422085
VISIT DATE: 08/03/2023
NARRATIVE
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The licensee CPR and First Aid certificate is current and expires (July 2024). The licensee's mandated reporter is current and will expire in March 2024. LPA obtained an updated facility roster reviewed, and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review.
The licensee last conducted an emergency on January, 2023. LPA directed the licensee to conduct an additional emergency drill as soon as possible. The licensee stated that she would conduct an emergency drill later in the day after naptime and email documentation to the LPA in terms of photographs. The LPA did not direct the licensee to conduct an emergency drill during the inspection because children were sleeping at the time of inspection.
LPA reviewed children files and found that C5 did not have complete vaccination information. The licensee stated she received proof of vaccination from C5’s mother prior to enrollment but had failed to properly log the information in the child’s file. The licensee stated she would communicate with C5’s mother to receive proof of vaccination, update her records, and email LPA proof of both vaccination and updated record keeping as soon as possible via email. LPA observed no other deficiencies in children’s files.
LPA observed that the licensee failed properly document and record safe sleep checks for infants in care. The licensee had the correct forms required to document safe sleep checks, but last recorded a 15-minute check in November of 2022. This is a violation of California Code of Regulations 102425(j)(1), and a Type B violation will be cited for this infraction.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

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SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Andrew ElliottTELEPHONE: (510) 363-5635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: AYCHILUHIM, HIRUT
FACILITY NUMBER: 013422085
VISIT DATE: 08/03/2023
NARRATIVE
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 Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Andrew ElliottTELEPHONE: (510) 363-5635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: AYCHILUHIM, HIRUT
FACILITY NUMBER: 013422085
VISIT DATE: 08/03/2023
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 Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

1 Type B Violation was Cited in Todays visit for failure to comply with CCR 102425(j)(1).

Exit interview conducted and report was reviewed with the licensee Hirut Jifar Aychiluhim.

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SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Andrew ElliottTELEPHONE: (510) 363-5635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/03/2023 04:12 PM - 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: AYCHILUHIM, HIRUT
FACILITY NUMBER: 013422085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

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 2 out of 2 instances which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Licensee will immediately begin documenting the time, date, and condition observed of each infant during each 15-minute interval of sleep. Infant safe sleep logs will begin to be kept and retained in children’s files for 3 years as of 08/04/2023.
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: Andrew ElliottTELEPHONE: (510) 363-5635
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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