073408999-1-8-2020-02-CC-LCHW-BKMTS4-20200108135832

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073408999
Report Date: 01/08/2020
Date Signed: 01/08/2020 01:58:39 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:	SEDIQUE, AMY		FACILITY NUMBER:	073408999
ADMINISTRATOR:	SEDIQUE, AMY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 944-5394
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	14	CENSUS:	DATE:	01/08/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	SEDIQUE, AMY		TIME COMPLETED:	02:20 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 Analyst (LPA), LaKeisha Chew met with Applicant Amy Sedique for the purpose of an announced Pre-licensing inspection, the home was toured with applicant inside and out for health and safety. Present during the inspection was fingerprint cleared husband Alex Sedique. Per the applicant 2 adults and 2 children ages 15 and 17 years old reside in the home. An fire safety inspection was conducted by East Contra Costa Fire Protection District on 10/28/2019 per special conditions: second floor and garage off limits to children in care. All areas identified on the facility sketch was inspected. This two story home consists of 5 bedrooms, 4 bathrooms, living room/dining room (play room) family room, (isolation area) kitchen, loft, attached 3-car garage and fenced backyard. LPA observed the home has child safety outlet plugs covers stove knob covers, and barrier gate for stairs.There are no bodies of water and no toxins or hazards found accessible to children in care. Mandated postings will be visible for public review in the entryway of living room. The facility plans to operate 7:00am to 6:00pm Monday through Friday. Applicant own the property. Proof of occupancy was shown by corporation grant deed. and a copy was obtained for the file. Applicant indicated there are no weapons, firearms or ammunition in the home. There is a fully charged 2A-10B:C fire extinguisher, working carbon monoxide/smoke detector on premises. The applicant is following new immunization law which pertains to day-care providers. Pediatric CPR and First Aid certificates was reviewed and expires on 10/2021. Mandated Reporter Training expires on 10/2021. Applicant Preventative Health and Safety Certificate was accomplished on 10/2019. The following areas are off-limits: Entire second level of home, and garage. 809-C continue next page…

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Lakeisha Chew	TELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020

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: SEDIQUE, AMY	FACILITY NUMBER: 073408999
	VISIT DATE: 01/08/2020

NARRATIVE

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An evaluation of the overall condition of this residence including telephone service, heating, and ventilation met compliance standards for safety and comfort

Applicant has been reminded of the following:

Fire and earthquake drills to be conducted every six months. Visual Supervision of children in care is always required.

This home is recommended for being licensed. An Exit interview was conducted with Applicant,.

A notice of site visit was posted and must remain posted for a period of thirty days for public review A copy of this report will remain on file for a period of three years for public review upon request and a copy should be available for review in the facility for a period of 3 yrs.

Applicant is encouraged to frequently visit our website at WWW.CCLD.CA.GOV for updates to current forms, laws, regulations and legislation pertaining to a Family Child Care Home

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Lakeisha Chew	TELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020

LIC809 (FAS) - (06/04)

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