214200171-11-26-2019-05-CC-FBTQ-BJAUZK-20191126150139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214200171
Report Date: 11/26/2019
Date Signed: 11/26/2019 03:01:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	SAMAN, EDNA		FACILITY NUMBER:	214200171
ADMINISTRATOR:	SAMAN, EDNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 250-9097
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	14	CENSUS: 9	DATE:	11/26/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:58 PM
MET WITH:	Edna Saman		TIME COMPLETED:	03:30 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) Farhan Bashir-Tariq met with the Licensee Edna Saman for an Annual Random Inspection on 11/26/19. The purpose of the inspection was explained. Present, there were 9 children in care with one Helper, Teresita Gala. Licensee lives with husband, father, mother and sister. All adults living or working in the home have fingerprints clearance on file. Licensee is operating within the capacity and ratio limits as of today 11/26/19.The hours of operation are M-F, 7:30 AM-5:30 PM. Licensee provides Breakfast, Lunch and 2 snacks. LPA and Licensee inspected the entire day care area for Health and Safety Hazards. All off limit areas are properly barricaded and made inaccessible to the children in care. Licensee states that there is no pool, spa or any other body of water in the home. Licensee states, there are no weapons or firearms in the home. Licensee states, there are no pets in the home. Cabinet in the bathroom has child protective locks. The house is in good repair and free of hazards with proper temperature and ventilation. There is a carbon monoxide detector, a smoke detector, a fully charged fire extinguisher and a working telephone available in the home. There is a First Aid kit available in the home. There is a variety of age appropriate toys in the home. Licensee and Helper both have CPR and First Aid cards valid until 12/2020. Discipline policy is communication and redirection. LPA reminded the Licensee to conduct the fire or emergency drills at least once every six months and drills must be logged. Licensee has log for each drill being conducted. Per licensee’s log, last drill was conducted on September 4, 2019. Licensee presented a current roster of children and a copy for LPA to collect. All posting requirements are met and posted near the main entrance. LPA reviewed children’s files of all the children present today. Children's files were current and complete. LPA reviewed the identification and emergency information form for every child for proper names and numbers filled. Adult files were complete with immunization records and first aid and CPR certification. Continuation on next page...

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SAMAN, EDNA	FACILITY NUMBER: 214200171
	VISIT DATE: 11/26/2019

NARRATIVE

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LPA reminded Licensee that All adults, 18 years and older living in the home, helper, or assistant must have finger print clearance and must be associated to the facility by submitting an LIC 9182 with a copy of CDL or CA. ID prior to having any contact with children in care failure to do so could result in an immediate civil penalty.

(IMS) policy was discussed. Licensee is not providing any medication to the children in care at this point. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA reminded Licensee that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA observed Licensee and helper's immunization records.

LPA reminded Licensee, As of January 1, 2018, all staff is required to complete Mandated Child Abuse Reporter Training (AB1207) every two years. The training can be obtained online at www.mandatedreporterca.com. LPA observed the training completion certificates for the Licensee and helper. LPA encourages the facility to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. Facility can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates. Safe Sleep Regulation, Safe Sleep Environment and SIDS handouts were provided to the Licensee.

>No deficiencies were cited today under Title 22 Division 12 of the California Code of Regulations.
This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit. Licensee was advised for any additional questions to call Office, M-F, 8AM-5PM at 650-266-8800 . For Rules and Regulations, visit the Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019

LIC809 (FAS) - (06/04)

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