304313702-4-29-2020-06-CC-RJCN-BP5VEN-20200429162237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313702
Report Date: 04/29/2020
Date Signed: 04/29/2020 04:23:55 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:	DIN, SAIMA		FACILITY NUMBER:	304313702
ADMINISTRATOR:	DIN, SAIMA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 940-6402
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	14	CENSUS: 0	DATE:	04/29/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Saima Din - Applicant		TIME COMPLETED:	04:30 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	Tele-inspection Licensing Program Analyst (LPA), Ryan Chan conducted an announced Pre-licensing inspection of the facility on today's date. LPA was allowed entry by applicant Saima Din and toured the facility with the applicant. Present during today's inspection was the applicant Saima Din, applicant’s spouse, applicants three minor children, applicant’s father-in-law, applicant’s mother-in-law, and applicant’s adult sister-in-law. Currently there are 5 adult residents and 3 minor children living in the home; no assistants. Applicant stated she is currently not registered with any Foster Care agency or holds a foster parent license. Applicant was reminded if changes to notify the licensing office. A review of the Facility Personnel Report Summary on this date (04/29/20) indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The facility is a two-story home with 4 bedrooms, 3 bathrooms, living room, dining room, kitchen, a front and backyard that are both fenced and a garage. Both the front and the backyard have gates which applicant stated will always be latched when children are in care. The applicant has designated the living room, the bathroom downstairs, the front yard, and the backyard as part of her day-care. Applicant has placed the second story as off limits and has placed a child proof gate at the bottom of the stairs to prevent the children from going to the second story, the same child proof gate is used to prevent access to the garage door. The applicant acknowledged the children may never enter the off-limit areas. Control of property was verified by LPA during today’s inspection via property tax statement. The applicant has a cell phone that is used for childcare. The applicant was informed if a cell phone is used for childcare, it must always remain on the premises during hours of operation. Applicant was informed and understands the home is to be free from smoking during hours of operation. Continued on page 2

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2020

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: DIN, SAIMA	FACILITY NUMBER: 304313702
	VISIT DATE: 04/29/2020

NARRATIVE

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The facility has a fireplace in the living room which has a metal screen, there are no wall heaters or wood stoves at the facility. Cleaning solutions/chemicals stored in the bathroom and kitchen are all made inaccessible by means of safety latches on the cabinet doors. Sharp knives and utensils located in the kitchen are all inaccessible by means of safety latches on the cabinet doors. The kitchen and dining room are made inaccessible using child proof gates. Poisons/Hazardous items are not stored on site, and none were observed. There is no body of water in the home. The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. The applicant stated there no weapons or firearms on the premises. When firearms are present, they must be locked and stored separately from the ammunition. During today's inspection, the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged.

EMSA approved PEDIATRIC CPR & PEDIATRIC First Aid are current for the applicant and expires on 08/17/2021. Applicant completed the 8-hour Preventative Health Practices and Nutrition Course with Maria Nevarez Martinez on 07/28/2019.

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 following was discussed with applicant: Individuals who are 18 years of age or older living or working in the home must be fingerprinted cleared prior to being present in the facility. LPA provide applicant with website for Live-Scan locations www.oag.ca.gov/fingerprints/locations for all adults complete LIC 9163.

Continued on page 3

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2020

LIC809 (FAS) - (06/04)

Page: 2 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: DIN, SAIMA	FACILITY NUMBER: 304313702
	VISIT DATE: 04/29/2020

NARRATIVE

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If adult is fingerprinted cleared and associated to another facility, licensee must submit a Criminal Record Transfer Request (LIC 9182) or Exemption Transfer Request form (LIC 9188). Contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182 or LIC 9188) with copy of a valid identification issued by State or Federal Government and Criminal Record Statement (LIC 508) to fax # (714)703-2831 prior to hiring adult. Failure to complete the clearance process or license association for any adult resident or assistant will result in a civil penalty assessment against the license.

LPA reviewed Unusual Incident Report (UIR) form (LIC 624B)-advised to contact Licensing Officer of the Day within 24 hours and complete the UIR within seven days by faxing LIC624B to (714)703-2831. LPA advised applicant to report to licensing any unusual incident or child absence that threatens the physical or emotional health or safety of any child or any changes to hours and days of operation and also for any changes to facility, including on/off limit areas and change in phone number.

LPA reviewed with applicant requirements of Disaster Preparedness drills (documented every 6 months). The LPA advised of Affidavit Regarding Liability Insurance (LIC 282) if did not purchase liability insurance and to maintain the form in the children's files, and Car Safety Seat pamphlet were discussed and provided to the applicant. Posting requirements which include but not limited to Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9141), Parents Rights (PUB 394), Notice of Site Visit (LIC 9213), and License (LIC 203). LPA reviewed with applicant the need to maintain records including but not limited to Children records and Staff/Adults records, (LIC 311D).

Applicant was informed of Mandated Reporter Training for self and all assistants. Department web site form was given to download forms, Title 22 regulations, and trainings on-line at http://www.ccld.ca.gov. The applicant was also informed to visit the website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.

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SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2020

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: DIN, SAIMA	FACILITY NUMBER: 304313702
	VISIT DATE: 04/29/2020

NARRATIVE

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LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

A copy of “A Child Care Providers Guild to Safe Sleep” was provided to applicant:

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
LPA reviewed with applicant 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 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

The applicant was given a pamphlet on Lead Exposure and was discussed with provider. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf

LPA confirmed the Facility Pre-Licensing Self-Certification Checklist was received and meet all requirements.

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SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2020

LIC809 (FAS) - (06/04)

Page: 4 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: DIN, SAIMA	FACILITY NUMBER: 304313702
	VISIT DATE: 04/29/2020

NARRATIVE

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The facility was in compliance for a LARGE Family Child Care Home with Title 22 Regulations at the time of inspection. A license will be issued after final review, in the event additional requirements are needed, the applicant will be notified.

Appeal Rights and the appeal rights process was discussed with the applicant. The applicant was informed all appeals must be in writing and received by the licensing office within 15 business days.

An exit interview conducted where the report was reviewed with the applicant. 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: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2020

LIC809 (FAS) - (06/04)

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