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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313443
Report Date: 08/06/2021
Date Signed: 08/06/2021 01:10:23 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:MATAR, ROUBAFACILITY NUMBER:
304313443
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee Ms. Matar Rouba TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ketki Desai conducted an unannounced required annual inspection along with the Change in Capacity. LPA observed licensee Ms. Matar Rouba in the home along with her assistant caring for 1 infant, who was picked up the parent shortly. Licensee was operating within the licensed capacity as specified on license (8)
Due to COVID 19 guidelines, LPA observed staff wearing face mask, social distancing and following CDC and Dept of Public Health Guidelines.
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. Currently there are 3 adults including the licensee living in the facility. Facility Day care hours are 8.00 am-5.00 pm, Monday through Friday. Licensee is providing care and supervision to children ages 3 months to 12 years of age ( Infants to School age).

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of locked doors with a safety lock on the three door handles and a safety gate at the entrance of the kitchen.
The child care area consist of the extended room behind the living room of the home. It is a new extended area with a half bathroom and a french door besides the bathroom leading to the side yard. The bathroom for children, was observed to be safe. It has a changing station, small step stool and a potty chair.
Children enter the home through main door of the home, the kids walk through the kitchen/ dining room and living area to gain access to the new Day care room, which is constructed and approved by the City. There are working carbon monoxide, smoke detector, and fire extinguishers 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. (If they have poisons, firearms and other dangerous weapons they shall be locked.) Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. ( Page-1)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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: MATAR, ROUBA
FACILITY NUMBER: 304313443
VISIT DATE: 08/06/2021
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There is a fireplace in the living room screened by (a glass cover) and inaccessible to children in care. The home has age appropriate toys for the ages served. During today’s inspection, LPA observed the Day care room was equipped with safe age appropriate toys and educational items. The room is well lighted and ventilated. It has two French doors. One door is locked and has a curtain over it. The Day care area is the only designated room used by the children. Licensee provides care and supervision to infants and all infant equipment's were safe and appropriate. Including a play PAC/ changing station and safe infant toys.
LPA verified there is a working telephone service (cellular service).

Licensee stated the side yard accessed through the Day care room is the designated out door area for children. Safe outdoor toys were observed it has concrete flooring with shade. There is a wooden safety gate installed making the other side of the yard inaccessible to children. Pet dog is in this area.

There is bodies of water on the premises. A pool . It is in an area, inaccessible to children. There is a separate side metal gate entrance next to the main door to gain access. Licensee also has a fenced gate with a bolted lock on one side making it inaccessible to children. There is a door in the Day care area, which is locked with two bolt locks from outside making the other side completely inaccessible to children. The pool is completely inaccessible to children from each ends.

The licensee does have a current roster of children in care, during inspection children's records were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance.

The licensee and assistant’s Pediatric CPR/First Aid certification is valid through 9/22 and 6/2023.
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 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. Licensee and assistants are current with this training. (Page-2)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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: MATAR, ROUBA
FACILITY NUMBER: 304313443
VISIT DATE: 08/06/2021
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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 she 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, immunization's, 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

CCLD website www.ccld.ca.gov 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. Licensee does not have lead training Certificate. LPA provided the training link : www.emsa.ca.gov . Licensee has completed the required Preventative Health and Safety training for Nutrition component.

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: MATAR, ROUBA
FACILITY NUMBER: 304313443
VISIT DATE: 08/06/2021
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NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

LPA reviewed with licensee the following safe sleep best practices:
· 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 if 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.

A copy of the Provider Information Notice (PIN) 20-24 CCP and Safe sleep regulation were provided to the Licensee.

In the areas that were evaluated, NO deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Licensee also has requested a Change in Capacity to her current License, and is seeking to change to a Large Family Child Care home with 14 children.
Anaheim Fire Prevention office have granted the clearance for a Large Family Child care (14) on July 16th 2021.

Licensee also has received the required consent from the Property Owner. (LIC9149) to operate as a Large Family Child care home.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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: MATAR, ROUBA
FACILITY NUMBER: 304313443
VISIT DATE: 08/06/2021
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Based on today's Inspection, Licensee is in compliance with Title 22 regulations for a Large Family Child care home.
License for a Large Family Child care home shall be issued upon Management approval.
Licensee shall be notified if additional information is needed.

An exit interview was conducted with Licensee Ms. Rouba Matar. Appeal Rights were explained.

The Licensee was provided a copy of 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 Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC809 (FAS) - (06/04)
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