013422963-9-4-2019-52-CC-WNOA-BFPNW3-20190904104851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013422963
Report Date: 09/04/2019
Date Signed: 09/04/2019 10:48:58 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:	MOUFARREJ, ANNE		FACILITY NUMBER:	013422963
ADMINISTRATOR:	MOUFARREJ, ANNE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 580-6577
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY:	14	CENSUS: 6	DATE:	09/04/2019
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Anne Moufarrej		TIME COMPLETED:	11:00 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

Licensing Program Manager (LPM) Wynn Norona conducted an unannounced Case Management inspection today, September 4, 2019. Present during the inspection was the licensee with her assistant and 6 children (3 infants and 3 preschoolers). The licensee submitted an application to update and move the main day care area to the newly constructed extension of the home with separate entrance. The additional room or extension of the home was toured for Health and Safety Inspection.

The extension has one bedroom, one bathroom, kitchen and family room which will all be ON LIMITS. The OFF LIMITS areas are the entire former home. There is a pool with self latching gate. There is a firearm in the home locked in safety vault in an OFF limits area inaccessible to children. All the cleaning products, toxic materials, medicines were stored and kept out of reach/inaccessible to the children. There is no fireplace in the new area. LPA inspected and verified that the fire extinguisher 3A40BC is fully charged, smoke detector, carbon monoxide detector is hard wire to the system. First Aid Kit is fully stocked. The home is properly ventilated for children's safety and comfort. There are appropriate toys and kids furniture that are safe to use and appeared to be well maintained. The applicant has completed the required training on preventive health practices including pediatric CPR and First Aid which expires on December 17, 2019. LPM obtained a copy of the current children's roster.

Licensee was reminded that ALL residents, assistants, volunteers, or frequent visitors that are 18 years of age or older must be fingerprinted; fingerprints must be submitted and a clearance must be received prior to an individual's employment, residence or initial presence in the facility; an immediate civil penalty of $100 per day and up to $3000 per person, per incident will be assessed.

----------------------------------- CONTINUED ON PAGE 2 -------------------------------------------

SUPERVISOR'S NAME: Diane Perez	TELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Wynn Norona	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: MOUFARREJ, ANNE	FACILITY NUMBER: 013422963
	VISIT DATE: 09/04/2019

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
26
27
28
29
30
31
32

Effective August 1, 2003 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 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Children's roster must be properly maintained and fire/disaster drills every six months must be documented. Mandated reporter and appeal rights were also discussed. Informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged to email ChildCareAdvocatesProgram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list.

Incidental Medical Services was discussed with the licensee. This facility is not providing Incidental Medical Services (IMS) at this time. Facility will submit a plan of operation if in the future the licensee provides any IMS services to a child in care.

An exit interview was conducted with the licensee. The use of the newly constructed extension of the home is recommended pending the following:

1. Set-up of the entire day care in the extension area with toys and furniture (pictures)

2. Set-up of the outdoor space with toys and play equipment (pictures)

3. Copy of the fire clearance approval

SUPERVISOR'S NAME: Diane Perez	TELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Wynn Norona	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2019

LIC809 (FAS) - (06/04)

Page: 2 of 2