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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312620
Report Date: 04/18/2022
Date Signed: 04/18/2022 03:37:39 PM


Document Has Been Signed on 04/18/2022 03:37 PM - 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:SHOHDY, NATALIEFACILITY NUMBER:
304312620
ADMINISTRATOR:SHOHDY, NATALIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 587-5750
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:14CENSUS: 5DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Assistant and licenseeTIME COMPLETED:
04:15 PM
NARRATIVE
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A 1 year inspection was conducted at the facility by Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek. Covid-19 Emergency Questionnaire were answered. LPA observed the facility is following CDC and Dept of Public Health Guidelines. LPA met with licensee's assistant, Kahled Shohdy at the time of arrival. The licensee, Natalie Shohdi arrived during inspection. The licensee and her assistant were not caring for any children. No children were observed at the time of arrival. Five children arrived during LPA's inspection. Per Licensee, operation hours will be Monday to Saturday, 9.00 AM to 7:00PM. Licensee states that she will care (art class instructions only) for children 6-15 years old, School age children only.
Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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. Currently there are 2 adults including the licensee and one minor child residing in the facility.
The art class is one room which is equipped with art tools and equipment. Licensee states that the side entrance has been designated as the main entrance to access the Art Room. Licensee has set up a covered tent extending the art room for the Day Care activities. Per Licensee children come through the side gate, attend the session between 45 minutes to one-hour session. There are no full day children present at the home. They only come for learning Art/ Paining.
There is a fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are not firearms and/or other dangerous
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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
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 4


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: SHOHDY, NATALIE
FACILITY NUMBER: 304312620
VISIT DATE: 04/18/2022
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weapons in the facility, and none were observed during today's inspections. During today’s inspection LPA verified there is a working phone service.

The licensee has a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed.
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 for licensee and any adult working with children 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. CPR and 1st aide certificate for the licensee was expired. This was cited on next page. Please see LIC809D.

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

The licensee understands they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone 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, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info:

https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: SHOHDY, NATALIE
FACILITY NUMBER: 304312620
VISIT DATE: 04/18/2022
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Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.


In the areas that were evaluated, the following deficiency was observed of the California Code of Regulations, Title 22, Division 12 during today’s inspection. Please see LIC 809D.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Natalie Shohdy.

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.

End of 3 pages of reports.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/18/2022 03:37 PM - 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: SHOHDY, NATALIE
FACILITY NUMBER: 304312620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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CPR Personnel Requirements 102416(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid. This requirement was not met by reviewing file, observing CPR and 1st aide for the licensee was expired on 1/4/22. The licensee failed to comply with this requirement of Regulations.
POC Due Date: 05/06/2022
Plan of Correction
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The licensee stated she would complete the course and would send a copy of the certificate to LPA's email address by the due date of 5/6/22
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4