343624184-5-9-2022-03-CC-GSIH-CE9S5H-20220509133422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624184
Report Date: 05/09/2022
Date Signed: 05/09/2022 01:34:31 PM

Document Has Been Signed on 05/09/2022 01:34 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:	SHAMAL, MURSAL		FACILITY NUMBER:	343624184
ADMINISTRATOR:	SHAMAL, MURSAL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 664-8834
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	14	CENSUS: 1	DATE:	05/09/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Mursal & Edrees Shamal		TIME COMPLETED:	01:45 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) Singh met with applicant, Mursal & Edrees Shamal, for an announced pre-licensing inspection at the facility. Applicant applied for family child care license due to change of location. Applicant was previously licensed (343623904) at different location and recently moved. Currently, applicant lives in two story single family home. Applicant owns the house. Child care will be provided in areas: Living room, Hallway, Bedroom in the hallway, Bathroom in hallway, Family room and Backyard. Off limit areas: Entire second floor, Kitchen and Garage. Applicant understands that all off limits areas must must remain inaccessible to children. Isolation of an ill child will be in family room or Living room. Applicant was notified that prior to use of any off limits area, the department must be notified. LPA Singh inspected the entire home with the applicant for health and safety hazards. The house has proper temperature and ventilation. All the toxins or dangerous materials are stored in off limit areas and are inaccessible for the children. Fireplace is barricaded. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector. There is first aid kit available. There is a variety of age appropriate toys available. As per the applicant, there are no firearms or weapons in the home. There is no pool, spa or any other body of water in the house. Applicant is informed that all adults, 18 years and older living in the home, helper or assistant must have criminal record clearance and must be associated to the facility by submitting an LIC 9182 with copy of CA DL or CA ID prior to having any contact with children in care. Failure to do so could result in an immediate civil penalty of $100.00 each day. See next page for continuation ..................

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: SHAMAL, MURSAL	FACILITY NUMBER: 343624184
	VISIT DATE: 05/09/2022

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LPA discuss licensing regulations and provided a copy of the list of documents to maintain in the facility. Licensing forms and posting requirements were reviewed with the applicant. Applicant has submitted record of all the required immunization, CPR and Mandated reporter training certificate. Applicant understands that fire/earthquake drills are to be conducted every 6 months and recorded. Applicant understands that baby walkers, bouncers, and excersaucers are not allowed. Smoking is prohibited in family child care homes. Licensee was informed about the Provider Information Notices (PINs) on CCLD website.

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

LPA review AB 1207 with the applicant. As of January 1, 2018 all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

The applicant is encouraged to frequently visit out website at www.ccld.ca.gov for licensing regulations and new updates. Applicant can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

Prior to issue license, facility needs to complete the following:
- An adult in the home must receive the criminal background clearance.

Copy of this report was reviewed and provided to applicant. This report will be kept in the facility file and will be made available for public review upon request. Desk Duty is available Monday through Friday between 8 AM - 5 PM at (916) 263-5744.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

LIC809 (FAS) - (06/04)

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