073405354-11-22-2022-02-CC-CFES-CLEUWN-20221122145703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073405354
Report Date: 11/22/2022
Date Signed: 11/22/2022 02:57:40 PM

Document Has Been Signed on 11/22/2022 02:57 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	JAMIL, KHULOOD K		FACILITY NUMBER:	073405354
ADMINISTRATOR:	JAMIL, KHULOOD K		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 681-2839
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	14	CENSUS: 0	DATE:	11/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Khulood Jamil		TIME COMPLETED:	03:10 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 11/22/2022 at 12:40pm, Licensing Program Analyst (LPA) Catherine Fernandes met with Licensee Khulood Jamil for an Unannounced Required Annual Inspection. Present during the inspection was the licensee and her fingerprint husband. There were no children in care at the time of the inspection. Residing in the home is Licensee, her fingerprint cleared husband and her elderly mother. Licensee’s home was toured for a health and safety inspection. The facility operates 7:30am – 5:30pm, Monday-Friday. The home is a single-story home that consists of four bedrooms and four bathrooms. The entrance to the day is side gate on the right side of the home when facing the house. The inside and outside of the home were observed to be neat, clean with age appropriate materials and toys for the children. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there are no firearms and no pets in the home. ON LIMITS AREA: the outside bedroom and bathroom (main area of day care), the family room, the bathroom in the family room, the Bedroom on the far left of the hallway, the kitchen and the main living room (used as only a walk through area) and the entire enclosed backyard. OFF LIMITS AREA: the garage, the master bedroom and bathroom, the hallway bathroom and the first bedroom on the right, which will be inaccessible by closed and/or locked doors or visual supervision. ISOLATION AREA: on the couch in the family room The home has a fully charged 3A40BC fire extinguisher located in the main classroom on the wall and a working smoke detector in the house and the main classroom, and a working carbon monoxide detector. Licensee has a working telephone and complete First Aid Kit. All required forms are posted and visible for public view in the childcare room. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 10/20/2022. The Licensee's CPR and First Aid certificate is current and expires on 10/23/2023. The Licensee was reminded of the responsibility as a mandated reporter and has provided proof of the required training for which was conducted on 1/20/22. LPA did not observe any bodies of water in or around the home. LPA reviewed five children’s files, three staff files and obtained copies of the facility roster, all were complete and current. REPORT CONTINUES ON 809C.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine Fernandes	TELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: JAMIL, KHULOOD K	FACILITY NUMBER: 073405354
	VISIT DATE: 11/22/2022

NARRATIVE

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Licensee was reminded that California Law requires Licensee 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 email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com. Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.
NO IMS IS BEING PROVIDED AT THIS TIME

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine Fernandes	TELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: JAMIL, KHULOOD K	FACILITY NUMBER: 073405354
	VISIT DATE: 11/22/2022

NARRATIVE

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LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page 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.

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

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

Exit interview conducted

Report and Appeal Right provided.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine Fernandes	TELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

LIC809 (FAS) - (06/04)

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