304313773-5-28-2020-06-CC-DVAA-BQ2U5G-20200528151643

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313773
Report Date: 05/26/2020
Date Signed: 05/28/2020 03:16:48 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:	ABU-JIBNEH, NARMIN		FACILITY NUMBER:	304313773
ADMINISTRATOR:	ABU-JIBNEH, NARMIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 232-3559
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	14	CENSUS: 0	DATE:	05/26/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Narmin Abu-Jibneh		TIME COMPLETED:	05:15 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	Licensing Program Analyst (LPA) Dean Valencia conducted an announced Prelicensing tele-inspection of the facility on today's date, in response to a change of location application. The LPA virtually toured the facility with the applicant. A review of criminal clearance records on this date indicates adults who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 3 adult residents in the home. Applicant is not currently registered with any Foster Care agency or holds a foster parent license. The facility is a two story home with 4 bedrooms, 3 bathrooms, living room, dining room, kitchen, laundry room, and backyard that is fenced. The applicant has designated a large living room and backyard as part of her day-care. Applicant has placed the second story as off limits and a second living room and garage and has placed child proof gates and door handles to prevent the children from entering the off-limit areas during operation hours. The applicant acknowledged the children may not enter the off-limit areas. Control of property was verified and a signed LIC9149 is on file. The applicant has a cell phone that is used for child care. Applicant was informed and understands the home is always to be free from smoking. The facility has a fireplace, and it is inaccessible, and will not be used while children are in care. Cleaning solutions/chemicals, utensils, and sharp knives located in the kitchen are all inaccessible by means of safety gates. Poisons/Hazardous items are not stored on site, and none were observed. There is a drained fountain in the back yard and applicant understands it is not to ever have water. 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. There is a firearm and ammunition in the home and they are both locked separately. 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. (continued on LIC809C)

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean Valencia	TELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2020

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: ABU-JIBNEH, NARMIN	FACILITY NUMBER: 304313773
	VISIT DATE: 05/26/2020

NARRATIVE

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Approved pediatric CPR/First Aid are current for the applicant and expires . Applicant completed the 8-hour Preventative Health Practices and Nutrition Course and this is on file. This facility plans to provide Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 oag.ca.gov/fingerprints/locations for all adult complete LIC 9163. 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) and advised to contact Licensing Duty Officer within 24 hours and complete the UIR within 7 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/or any changes to facility, including on/off limit areas and phone number. LPA reviewed with applicant requirements of Disaster Preparedness drills (completed and 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.(continued on LIC809C, page 3)

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean Valencia	TELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2020

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: ABU-JIBNEH, NARMIN	FACILITY NUMBER: 304313773
	VISIT DATE: 05/26/2020

NARRATIVE

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Department web site form was given to down load 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. LPA reviewed Title 22 Regulation Section 102423 Personal Rights.

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
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. AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf

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.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean Valencia	TELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2020

LIC809 (FAS) - (06/04)

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