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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312693
Report Date: 10/06/2023
Date Signed: 10/06/2023 04:38:45 PM


Document Has Been Signed on 10/06/2023 04:38 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:SULEIMAN, RANAFACILITY NUMBER:
304312693
ADMINISTRATOR:SULEIMAN, RANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 293-2690
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:14CENSUS: 2DATE:
10/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Licensee, Rana SuleimanTIME COMPLETED:
04:45 PM
NARRATIVE
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On 10/06/23, Licensing Program Analyst (LPA) Dianna Valdez Santana conducted an unannounced case management visit to deliver deficiencies noted. LPA was assisted by licensee, Rana Suleiman. During today's inspection, LPA and licensee toured the facility and census was taken as follows: 1 staff and 2 children present. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.


During today's inspection LPA Valdez Santana reviewed children and staff files. LPA observed that the licensee was not previously documenting 15 minutes sleep log check. During staff file review, LPA observed that licensee had an expired CPR certificate, expired 6/30/23.

Based on LPA's inspection of the facility files, the following two Type B violations were observed is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 102425(j)(2) Infant Safe Sleep and 102416(c) Personnel Requirements on the attached LIC 809D.

Exit interview was conducted with licensee, Rana Suleiman. The Notice of Site Visit was posted. Facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The Licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days.

End of Report.

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
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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Document Has Been Signed on 10/06/2023 04:38 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: SULEIMAN, RANA
FACILITY NUMBER: 304312693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
CCR
102425(j)(2)

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2)The provider shall check and document the following:(A)Labored breathing. (B)Signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness.(C)Infants up to 12 month of age who are sleeping in a position other than on their back.

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Since LPA provided Licensee with a 15 min log template, Licensee has been documenting the infant's sleeping. Licensee showed documentation to LPA.
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This requirement was not as evidence by:
Licensee was not able to show proof of 15 min check documentation.
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Type B
10/06/2023
Section Cited
CCR102416(c)

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102416(c) Personnel Requirements: (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
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Licensee already renewed her CPR/Pediatric First Aid on 8/22/23 expires on 8/22/25.
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as evidenced by:
Licensee had an exipred CPR certification. CPR had expired on 6/30/23
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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: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
LIC809 (FAS) - (06/04)
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