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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411218
Report Date: 08/16/2022
Date Signed: 08/16/2022 11:47:07 AM


Document Has Been Signed on 08/16/2022 11:47 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:MIRZA FAMILY CHILD CAREFACILITY NUMBER:
197411218
ADMINISTRATOR:MIRZA, MUMTAZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 838-1649
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:12CENSUS: 6DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mumtaz MirzaTIME COMPLETED:
12:00 PM
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On 8/16/2022, Licensing Program Analyst (LPA) Lillian Casillas conducted an unannounced Annual Required Inspection and was met by Licensee, Mumtaz Mirza. Also present was/were Staff #1 (S1). Days and hours of operation are Monday through Friday, 8:30am to 5:00pm. LPA observed 6 children in care.

This facility is an one-story single family home with 3 bedrooms, 2 bathrooms, kitchen, dining room, front yard, back yard, laundry room, and garage. The primary child care areas are living room and dining room. In the living room, LPA observed 2 sofas and 1 pack n play. In the dining room, LPA observed a dining table with 4 chairs and a bench. LPA also observed 1 pack n play. Bathroom 1 is located in the hallway. LPA observed 1 toilet, 1 sink, and 1 shower/bath tub, which was free of shampoos and soaps. In the front yard, LPA observed a grassy area enclosed by a fence. LPA observed age-appropriate children's toys and play equipment. Off-limits areas are: kitchen, bathroom 2, 3 bedrooms, laundry room, and backyard. The kitchen is made inaccessible by use of child safety gates blocking off the living room and dining room. Licensee stated bedrooms and laundry room are made inaccessible by supervision of the children. There is no swimming pool on the premises. There are no firearms or ammunition on the premises. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible as these items are stored in the laundry room. There are no fireplaces or open face heaters in the home. There is a working 2A10:BC fire extinguisher secured to the wall in the kitchen, 1 smoke detector in the dining room, and 1 carbon monoxide detector in the hallway. and adequate heating and ventilation for safety and comfort.

There are currently 4 infants in care. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. LPA informed Licensee of physical checks on sleeping infants every fifteen minutes to document any signs of distress, which includes but is not limited to: flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room.


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SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MIRZA FAMILY CHILD CARE
FACILITY NUMBER: 197411218
VISIT DATE: 08/16/2022
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Infants up to 12 months of age are placed on their backs for sleeping. LPA informed licensee that Individual Infant Sleeping Plan is required for each infant up to 12 months of age. Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children.

LPA reviewed all children’s files and observed files. Licensee’s Mandated Reporter Training was completed on 8/28/2021. Licensee’s pediatric CPR/First Aid expires on 4/10/2023.

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. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

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.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited. Two Technical Violations is being issued regarding the LIC 9227 Individual Sleeping Plan forms and 15 minute sleeping checks that were not found in the infant's files

A Notice of Site Visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Mumtaz Mirza.

SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
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