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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622691
Report Date: 05/15/2023
Date Signed: 05/15/2023 04:38:46 PM


Document Has Been Signed on 05/15/2023 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:ESMAIL, EZDIHARFACILITY NUMBER:
343622691
ADMINISTRATOR:ESMAIL, EZDIHARFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 624-0366
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:14CENSUS: DATE:
05/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ezdihar EsmailTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Erwin Tjhia and Jennie Tedlos met with the licensee, Ezdiha Esmail for an open complaint visit. Licensing staff toured the facility, observed the care and supervision of the children.

They were 12 children present during the visit. There was also two assistant present who were helping with the children in care. One adult assistant, did not have criminal record clearance and/or facility associations, which poses an immediate health, safety or personal rights risk to persons in care.

Deficiencies were cited on the subsequent pages of this report. A Civil Penalty in the amount of $100 was also assessed today.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports and LIC 809D in each child's files.

This report was reviewed and discussed with licensee. A Notice of Site Visit and appeal rights were provided.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
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 05/15/2023 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833


FACILITY NAME: ESMAIL, EZDIHAR
FACILITY NUMBER: 343622691

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/16/2023
Section Cited
CCR
102416(d)1

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(d) Prior to employment or initial presence in the child care home, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations
This requirement is not met as evidenced by:
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The licensee stated that the staff will not come to the facility until she is fingerprinted cleared. The licensee will check with the licensing office for the individual's livescan status.
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Based on observation, and interview, the licensee did not comply with the
section cited above by having an adult without
fingerprint clearance at the facility today, helping the children in care, which poses an immediate health, safety or personal rights risk to children in care.
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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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
LIC809 (FAS) - (06/04)
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