073407334-11-4-2019-02-CC-MGUT-BHM254-20191104160456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073407334
Report Date: 11/04/2019
Date Signed: 11/04/2019 04:05:45 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:	KHALIFA, ASMAA		FACILITY NUMBER:	073407334
ADMINISTRATOR:	KHALIFA, ASMAA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 393-3329
CITY:	HERCULES	STATE: CA	ZIP CODE:	94547
CAPACITY:	14	CENSUS: 12	DATE:	11/04/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Asmaa Khalifa		TIME COMPLETED:	04:15 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 11/4/19, Licensing Program Analyst (LPA), Melissa Guirit, met with licensee Asmaa Khalifa for an UNANNOUNCED RANDOM INSPECTION. Present for this inspection were the licensee, fingerprint cleared assistant, Grace Carver-Laughlin, 1 infant, 10 preschoolers, and 1 school age child. The home was toured to conduct a Health and Safety Inspection. The facility's operating hours are from 6:30 AM to 6:00 PM. The home is two story. The home consists of 4 bedrooms, loft, 2 1/2 bathrooms, family room, living room, dining room, kitchen, converted garage, and backyard. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the family room, living room, dining room, kitchen, downstairs half bathroom, converted garage, and backyard. The OFF LIMIT AREAS are the entire upstairs area which will be inaccessible by closed and/or locked doors, child barricade gates, and visual supervision. The ISOLATION AREA will be in the family room. The outdoor play area is free from defects or dangerous conditions and is completely fenced with 100% supervision. The shed on the left side of the backyard is locked to prevent access by children. There are ample age appropriate toys that appear to be safe and in good condition. 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 and it was observed that there are no toxins or hazardous items accessible today. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone, and fully stock First Aid Kit. The licensee CPR and First Aid certificate is current and expires 11/2019. Per licensee, she will be renewing her CPR and First Aid by the end of the month. Licensee completed the Mandated Reporter Training which expires on 03/2020. Licensee is in compliance with the new immunization law. The fireplace in the living room is screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills with the last one on 10/2019. See 809-C for continuance.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2019

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: KHALIFA, ASMAA	FACILITY NUMBER: 073407334
	VISIT DATE: 11/04/2019

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(6) Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review.

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. All forms can be downloaded at www.ccld.ca.gov .http://www.myccl.gov/

Incidental Medical Services (IMS) policy was discussed with licensee.

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: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2019

LIC809 (FAS) - (06/04)

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