013422837-6-3-2021-52-CC-RRED-C3MTZH-20210603151023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013422837
Report Date: 06/03/2021
Date Signed: 06/03/2021 03:10:33 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:	MOHAMMED, SHAHEEN		FACILITY NUMBER:	013422837
ADMINISTRATOR:	MOHAMMED, SHAHEEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 515-0419
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY:	14	CENSUS:	DATE:	06/03/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Shaheen Mohammed		TIME COMPLETED:	03:15 PM

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 6/3/2021 at approximately 1:05 PM Licensing Program Analyst (LPA) Renee Reed met with Licensee Shaheen Mohammed for an Unannounced 1-year required Inspection. Present during this inspection was licensee, licensee’s spouse Gazanfurali, licensee's assistant Gurjeet Kaur , licensee's and 9 pre-school age children in care. The home was toured to conduct a Health and Safety Inspection. The licensee operates Monday thru Friday, 8:00 AM until 5:30 PM. The home is two stories which consists of 4 bedrooms, 2 bathrooms and laundry room located on the 2nd floor; day care/living room, kitchen, dining area, 1/2 bathroom, garage and fenced backyard located on the 1st floor. The home is neat and clean with centralized heating/air and ventilation for safety and comfort. The OFF LIMIT AREAS are the entire 2nd floor which is barricaded by a gate by the stairs and the garage which will be inaccessible and require visual supervision at all times. The ISOLATION AREA will be the dining room. There are age appropriate toys for children to play indoors and outdoors. 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. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone, and first aid kit. The licensee's Health and Safety training is complete and CPR and First Aid certificate expired on 3/2/2021, LPA Reed received a signed CPR/ & First Aid Attestation form, which is posted. LPA also advised to register for an upcoming CPR & First Aid as the Attestation Waiver may cease. The home has no fireplace. Per Licensee, there are no firearms in the home. At 1:30 PM LPA reviewed children's and assistant files. Licensee stated the assistant does not have a mandated reporter training certificated due to not speaking English, an exception is has be given for this reason. See 809-C

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Renee Reed	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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: MOHAMMED, SHAHEEN	FACILITY NUMBER: 013422837
	VISIT DATE: 06/03/2021

NARRATIVE

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Licensee was reminded Mandated Reporter Training is required every two years, licensee's mandated reporter training expired 3/30/2020, LPA gave an advisory to have mandated reporter training completed and to be sent to me with 7 days which is 6/10/2021. mandatedreporterca.com

The licensee was reminded to conduct fire and disaster drills at least twice a year. LPA observed all required postings are visible for public review.

LPA, is reminded to review the CCLD.ca.gov website to view most recent Provider Information Notices.

LPA reminded licensee to report to licensing any structural changes to the home. Licensee is reminded to report unusual incident reports within the next business day by telephone.

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

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 and appeal rights provided.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Renee Reed	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC809 (FAS) - (06/04)

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