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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304202176
Report Date: 04/20/2022
Date Signed: 05/11/2022 09:28:24 AM


Document Has Been Signed on 05/11/2022 09:28 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:RAHMAN, RIZWANAFACILITY NUMBER:
304202176
ADMINISTRATOR:RAHMAN, RIZWANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 651-8175
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:14CENSUS: 6DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Rizwana Rahman, LicenseeTIME COMPLETED:
03:15 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA), Alanna Gontarek. LPA met with Licensee, Rizwana Rahman. Licensee gave LPA a tour of facility indoors and outdoors. Census was taken. LPA observed licensee and Licensee's assistant/spouse, Shakeel Rahman caring for 6 children; which included (3) infants, (2) preschool age children, and (1) school age child. Also present during this inspection was Licensee's spouse, Shakeel Rahman. Licensee was operating within the licensed capacity as specified on license.

This is a two-story home which consists of 3 bedrooms, 2 bathrooms, kitchen, dining room, daycare/living room, laundry room, front yard (not fenced) and patio (fenced). Daycare areas include: One downstairs bathroom, daycare room/living room, laundry room, kitchen, dining room area, and front yard. There is a fireplace located in the daycare/living room and screened by a toy storage, and inaccessible to children in care. Per Licensee, areas off limits to children and parents include: Upstairs (3) bedrooms, patio(fenced), and (1) upstairs bathroom. Upstairs area is made inaccessible via baby safety gate. Per licensee, provides food for children in care. There were no pets observed on the premises.

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.

The licensee states that 1 additional adult (Licensee's spouse) currently lives in the home. Per Licensee, she currently has one assistant (licensee's spouse). All adults present in the home have obtained a criminal record clearance or exemption prior to residing in the licensed child care home.



All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via a cellphone that is used and the cellphone stays at the facility during operation hours. There is ventilation and heating (central). The following was observed and reviewed during this inspection. LPA observed First Aid kit and supplies located in the the hallway storage closet. Per Licensee, knives are stored in
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: RAHMAN, RIZWANA
FACILITY NUMBER: 304202176
VISIT DATE: 04/20/2022
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the kitchen in an upper cabinet. Poisons, detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children via baby safety gates. Per Licensee, makes water available via bottle water. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock. The restroom that children use was observed to be safe and sanitary. Per Licensee, there are no firearms stored in the home. LPA observed cleaning supplies located on the kitchen counter, and on an above shelf in the laundry room, and are inaccessible to children in care. The home is observed to be clean and orderly. Where children less than five years old are in care, stairs are fenced or barricaded. LPA observed a child safety gate which keeps stairs inaccessible to children. There are toys available for children located in the daycare/living room. Appropriate sleeping arrangements (blankets) were observed in the nap room. Per licensee, cares for (3) infants at this time. LPA observed (2) Pack N' Play (Play yards) located in the daycare/living room. Per licensee, she cares for children ages birth to 13 years. LPA observed all electrical outlets to have covers.
The valve on the required 2A10BC fire extinguisher indicates fully charged. Per Licensee, purchased fire extinguisher on 10/31/21. Smoke and carbon monoxide detectors were tested and are operable. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Per Licensee, does not document drills. Licensee stated has not conducted drills in 2 years. This violates Title 22: 102417(g)(9)(A)(1). Please see attached LIC 809D page.
Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted.
Licensee stated she uses the front yard area for outdoor play 2-3 times a week in the morning time. Licensee stated provides 100% supervision when playing outside in front of facility. There are no bodies of water on the premises.

Record Review: The licensee has a current roster of children in care. A total of (6) Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information that contains all the information specified by regulation (LIC 700) and found to be in compliance. The licensee and licensee's spouse/assistant’s CPR/Pediatric First Aid certification expire on 5/2022.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles, and Influenza for licensee and assistant were reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. The licensee and licensee's assistant/ spouse are exempt from this requirement due to the training not being available in Hindi.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: RAHMAN, RIZWANA
FACILITY NUMBER: 304202176
VISIT DATE: 04/20/2022
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LPA inspected kitchen and LPA observed 1 high chair, one swing, 2 car seats. LPA advised Licensee to not use the car seats in the daycare. Car seats are for transportation only. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories. These items are not permitted in a family child care facility. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, CPR/Pediatric First Aid, and mandated reporter training.

CCLD website was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the licensee.

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf . AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: RAHMAN, RIZWANA
FACILITY NUMBER: 304202176
VISIT DATE: 04/20/2022
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· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping

The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

LPA discussed: Individual Sleeping Plan (LIC 9227) needs to completed for children ages birth to 12 months. The 15-minute Sleep chart needs to be completed for infants ages birth to 2 years. The documentation needs to be completed during duration of infant sleep. LPA provided a sample Sleep Chart.

Incidental Medical Services (IMS) policy was discussed. 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 advised the licensee to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov.


Capacity Handout (Small & Large) was provided during this inspection.

Based on the LPA’s observations and records review, the following deficiency listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.
Exit interview was conducted and report (LIC 809) was reviewed and provided to the licensee, Rizwana Rahman. The licensee was also provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: RAHMAN, RIZWANA
FACILITY NUMBER: 304202176
VISIT DATE: 04/20/2022
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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
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 05/11/2022 09:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: RAHMAN, RIZWANA
FACILITY NUMBER: 304202176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with Licensee and record review, at 12:50 p.m., during interview conducted with Licensee, Licensee stated has not conducted a disaster drill in 2 years, and does not document the drills. At 1:30 p.m., during record review, LPA did not observe a disaster drill record on file. The licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2022
Plan of Correction
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Per Licensee will conduct a disaster drill (Earthquake and Fire) by the due date of 4/26/22. Per Licensee, will submit a copy of the completed drill via email to LPA Gontarek.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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