073409017-3-15-2023-02-CC-MDOY-CPXQ6T-20230315115404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073409017
Report Date: 03/15/2023
Date Signed: 03/15/2023 11:54:36 AM

Document Has Been Signed on 03/15/2023 11:54 AM - 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:	AHMED, IRFANA		FACILITY NUMBER:	073409017
ADMINISTRATOR:	AHMED, IRFANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 568-2577
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	14	CENSUS: 11	DATE:	03/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Irfana Ahmed and Samrah Sameer		TIME COMPLETED:	12:10 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 March 15, 2023, Licensing Program Analysts (LPAs) Melissa Domantay and Melissa Guirit conducted an unannounced Annual Inspection with Licensee Irfana Ahmed. Residing in the home is the licensee, her fingerprint cleared husband and adult daughter. Present upon arrival was fingerprint cleared assistant and 10 preschool children and 1 infant. Operating hours are 7:00AM to 6:00PM, Monday through Friday. The home is a two story house that consists of five bedrooms and two and a half bathrooms. The OFF LIMIT AREAS are the entire upstairs, the kitchen, the formal dining/living room, the laundry room, the left side of the backyard and the garage, which will be inaccessible by closed and/or locked doors or visual supervision. The ON LIMIT AREAS are the family room which is the main area of the day care, the breakfast nook in-between the family room and the kitchen, the downstairs bathroom and bedroom and the large part of the backyard. The ISOLATION AREA will be in the downstairs bedroom. Disinfectants, cleaning solutions, and other items that are dangerous to the health and safety of children were stored in places inaccessible to them. The outdoor play area is a fenced in backyard, there is an off limit area on the left side of the home that has a separate fence preventing children from entering. LPAs observed the following precautions, there is a fire place in the family room that is covered, cabinets and drawers in the breakfast nook have safety latches and the off limit areas have gates to prevent access. Per Licensee, there are no firearms in the home. The home has a fully charged 2A10BC fire extinguisher on the wall in the breakfast nook and pull down fire alarm on the wall next to the on limit bedroom. A working smoke detector in the family room and a carbon monoxide detector next to the kitchen, the telephone is in working condition, and the First Aid Kit is complete. The Licensee's CPR and First Aid certificate is current and expires on 10/16/23. The home's last fire drill was conducted on 9/9/2022. Licensee has confirmed no children in care require medication. Required posters are posted on the parent board. Report continues on 809 c.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Melissa Domantay	TELEPHONE: 510-725-7021
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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: AHMED, IRFANA	FACILITY NUMBER: 073409017
	VISIT DATE: 03/15/2023

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The Licensee was reminded of the responsibility as a mandated reporter and has provided proof of the required training for child care providers.

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. All forms can be downloaded at www.ccld.ca.gov .

There are no deficiencies cited today. An exit interview was conducted with Licensee and copy of report, notice of site, and appeal rights provided to Irfana Ahmed and Samrah Sameer

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Melissa Domantay	TELEPHONE: 510-725-7021
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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