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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422131
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:02:47 PM


Document Has Been Signed on 03/03/2022 02:02 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:ALI, NAZIAFACILITY NUMBER:
013422131
ADMINISTRATOR:ALI, NAZIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 952-9914
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:14CENSUS: 3DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Nazia Ali- LicenseeTIME COMPLETED:
02:05 PM
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On 3/3/22 at 12:00pm, Licensing Program Analyst Briana Plumboy met with licensee Nazia Ali for an UNANNOUNCED RANDOM INSPECTION. Present for this visit was licensees fingerprint clear and associated daughter Marium Ali, 2 infants, and 1 preschool age child. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 7:30am until 5:45pm.

The home is two stories. The ON LIMIT AREAS are the family room, garage (for pick up and drop off with parents only/ the garage side door is the entrance and exit the licensee uses for access to the childcare), 1/2 bathroom, kitchen and backyard. The ISOLATION AREA will be a section in the family room. The children will enter through the side of the home and walk through the garage to get to the childcare. The OFF LIMIT AREAS are the entire upper level of the home which consists of 4 bedrooms and 2 bathrooms and the lower level of the home living room which will be inaccessible by closed and/or locked doors and visual supervision. There is a child safety gate which acts as a barricade to the off limit areas. The BACKYARD play area is completely fenced. There are no anchored play structures. The outskirts (garden) and deck on the right side of the backyard are off limits to children in care. There are toys that appear to be in good condition during today's inspection. There are no pools, hot tubs or any other bodies of water present in the on limit areas during today's inspection. All hazardous materials and toxins were observed to be kept out of the reach of children during the inspection. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide, and working telephone. The licensees CPR and First Aid certificate expires 08/03/23. The licensee received a certificate of completion in mandated reporter training on 2/21/22. The licensee is in compliance with the immunization law. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. Facility roster copy obtained. Licensee is in ratio today. Forms are visible for public review, and located inside the garage today. The facility last documented a disaster drill on 02/11/22. See 809-C for continuance
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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: ALI, NAZIA
FACILITY NUMBER: 013422131
VISIT DATE: 03/03/2022
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Incidental 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

Licensee was encouraged to frequently visit our website at ccld.ca.gov for licensing regulations and updates.

Licensee is reminded that ALL assistants, volunteers, and staff, 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



LPA discussed the safe sleep regulations with licensee Nazia Ali 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 Nazia Ali 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.

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

See 809D for cited during today's inspection. Appeal rights provided and discussed. Exit interview conducted and report was reviewed with licensee Nazia Ali.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/03/2022 02:02 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: ALI, NAZIA
FACILITY NUMBER: 013422131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2022

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 1 out of 3 childrens files does not have a signed Lic. 282 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
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Licensee will have child 03's parent/authorized representative sign the Lic. 282 at pick up today or drop off tomorrow and submit a photo by text message to LPA Plumboy.
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: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
LIC809 (FAS) - (06/04)
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