<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406222
Report Date: 01/28/2020
Date Signed: 01/28/2020 01:26:06 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:BEKHIT, SAMIAFACILITY NUMBER:
073406222
ADMINISTRATOR:BEKHIT, SAMIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 888-3834
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:14CENSUS: 11DATE:
01/28/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Samia BekhitTIME COMPLETED:
01:35 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
Licensing Program Analysts (LPAs) Cherie Acosta and Jaylena Miller conducted an unannounced Plan of Correction (POC) inspection. Present during the inspection was the licensee, her fingerprint cleared husband and one school aged child, three infants and seven preschool aged children in care

During LPA's last inspection on 12/20/19 the licensee was cited for the following deficiencies:

- LPA observed children napping in the bedroom on the second level of the home which is off limits to children.

- during file review, children's file were found to be incomplete

During today's inspection, LPA's arrived during nap time, children were napping in the on limits area only. Licensee submitted an updated facility sketch. Licensee understands that children are not allowed in the off limits area of the home and agrees to remain in compliance. This citation is cleared during today's inspection.

Children's files were reviewed during today's inspection, all children's file were complete except C8's file which was missing the Consent for Medical Treatment form (LIC627).
Licensee is cited again today for the incomplete file.

Exit interview was conducted with Samia Bekhit.
Notice of Site Visit was provided during the inspection and must be posted for 30 days.
Licensee was provided a copy of the appeal rights.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie AcostaTELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2020
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: BEKHIT, SAMIA
FACILITY NUMBER: 073406222
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2020
Section Cited

1
2
3
4
5
6
7
An Operation of a Family Child Care Home emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible
8
9
10
11
12
13
14
adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requiremnet was not met as evidenced by: C8 did not have, form LIC627, Consent for Emergency Medical Treatment completed, which poses a potential risk to the health and safety of children in care.
8
9
10
11
12
13
14
Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie AcostaTELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2