304312883-9-24-2019-06-CC-MQUO-BGBUWT-20190924155716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304312883
Report Date: 09/24/2019
Date Signed: 09/24/2019 03:57:33 PM

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:	KHAMIS, NAJWA JOSEPH		FACILITY NUMBER:	304312883
ADMINISTRATOR:	KHAMIS, NAJWA JOSEPH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 313-5655
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY:	14	CENSUS: 12	DATE:	09/24/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Najwa Joseph Khamis		TIME COMPLETED:	04:15 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	An inspection was conducted at the facility by Licensing Program Analyst (LPA) Mila Quinto. The LPA toured the facility with licensee, Najwa Khamis. A review of adult records indicates that all facility residents, staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There is presently 1 adult living in the home. During today's inspection the home and grounds were toured, and the licensee was operating within the licensed capacity. There were 2 infants, 8 preschool and 2 school age children in care. Also present assisting with the day care children was the licensee's assistant. Licensee is operating 24 hours, Monday through Saturday. This is a two story with four bedrooms and two-bathroom home. The floor plan was verified and no changes from previous visit. The off-limits areas were made inaccessible to children by means of baby gates, latches and child proof door knobs. The outdoor area is free from hazards. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. The licensee stated poisonous items are not stored on site, and none were observed during today's inspection. The home provides safe toys, equipment, and materials. During today's inspection each child was observed to have safe, healthful and comfortable accommodations, furnishings, and equipment. There is a working carbon monoxide detector, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. The licensee has a current roster of children in care (obtained copy of roster). The facility has conducted an emergency drill within the past six months and log was verified. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's visit. The licensee's pediatric CPR/First Aid Certificate expires on 07/07/2019. Children's records were reviewed and in compliance.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila Quinto	TELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KHAMIS, NAJWA JOSEPH	FACILITY NUMBER: 304312883
	VISIT DATE: 09/24/2019

NARRATIVE

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At 2:00 pm, LPA reviewed immunization records for both licensee and assistant. Licensee provided proof of influenza and a written decline of flu shot for the assistant. Licensee and assistant do not have proof of immunization against pertussis and measles. Assistant also does not have proof of TB. Per licensee, she will obtain the immunization records from the Doctor.

Beginning March 31, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years, per A.B. 1207. Licensee has completed the required mandated reporter training and provided a copy of certificate dated April 9, 2018 to LPA. The licensee's assistant is exempt from this requirement due to the training not being available in Arabic.

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/childganda.htm.

LPA provided the licensees with the copy of Safe Sleep, Never Shake a Baby and Lead handout.
Licensee was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed and cited today, see LIC 809D.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila Quinto	TELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019

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: KHAMIS, NAJWA JOSEPH	FACILITY NUMBER: 304312883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/08/2019 Section Cited	1 2 3 4 5 6 7	1597.622(a)(1) Employee and Volunteer Immunization: Immunization's. Commencing September 1, 2016, 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. The licensee had proof of immunization against influenza on file and the assistant provided a written decline of the flue shot.
	8 9 10 11 12 13 14	Based on observation and interview, the licensee failed to provide proof of immunization against measles and pertussis for both licensee and assistant. This poses a potential health and safety risk to children in care.	8 9 10 11 12 13 14
Type B 10/08/2019 Section Cited	1 2 3 4 5 6 7	102369(b)(9) Application for License. Licensees and any adult in the home, shall provide evidence of a current tuberculosis clearance, performed and signed by a physician not more than one year prior to or seven days after first day of employment.
	8 9 10 11 12 13 14	Based on observation and interview, TB test results are needed for assistant. This poses an immediate risk to the health and safety of children in care.	8 9 10 11 12 13 14

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 Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila Quinto	TELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019

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: KHAMIS, NAJWA JOSEPH	FACILITY NUMBER: 304312883
	VISIT DATE: 09/24/2019

NARRATIVE

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Inspection report reviewed and exit interview was conducted. Notice of Site Visit was posted during the visit. 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. Appeal rights provided and explained. The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. First level should be sent to the regional manager to the address listed above. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila Quinto	TELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019

LIC809 (FAS) - (06/04)

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