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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624236
Report Date: 04/06/2022
Date Signed: 04/06/2022 11:44:44 AM


Document Has Been Signed on 04/06/2022 11:44 AM - 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:ALUBAYDI, IMANFACILITY NUMBER:
343624236
ADMINISTRATOR:ALUBAYDI, IMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 717-4222
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY:14CENSUS: 0DATE:
04/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Iman AlubaydiTIME COMPLETED:
12:00 PM
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On 04/06/22 at 9:00am, Licensing Program Analyst (LPA) Jan Hoshida met with Applicant Iman Alubaydi for the purpose of a pre-licensing inspection. Applicant’s fingerprint clearance is currently in process. Applicant has applied for a Large Family Child Care License. On 3/23/22, Community Care Licensing received a fire clearance for the home from the Sacramento City Fire Department.

During the inspection, LPA Hoshida requested a tour of the facility. LPA and Applicant conducted a health and safety inspection inside and out the home. The two-story home has three bedrooms, two bathrooms, one master bathroom, kitchen with living room, nap room, play room, laundry room, garage, and upstairs balcony, and fenced back yard. The off-limits areas in the home are the entire upstairs (which includes the kitchen with living area), laundry room, left side yard, and garage. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. Functioning smoke and carbon monoxide detectors and fire extinguisher were observed in the home. LPA observed a fire pull on the wall in the play room area. Preventative health and safety, current pediatric CPR and first aid training was verified and expires on 02/09/2024. There is no fireplace in the home. Supervision was discussed and applicant understands that children must be 100% supervised in unfenced yards. Immediate Civil Penalty regulation and deficiencies were reviewed. Licensing documents were posted in the play room area of the home. Applicant will be offering day care services from Monday through Friday from 8:00 am to 5:30 pm.

The backyard is fenced and gated. Applicant stated that she understands that poisons must be kept inaccessible to children in care by stored under lock and key. Applicant stated there are no weapons in the home.

REPORT CONTINUED ON NEXT PAGE
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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: ALUBAYDI, IMAN
FACILITY NUMBER: 343624236
VISIT DATE: 04/06/2022
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LPA consulted applicant regarding the following topics: Safe Sleep, Type A vs. Type B deficiencies, complaints, LPA’s right to interview children without parental consent, civil penalties, incidental medical services, placement of detergents, placement of poisons, placement of medicines, announced vs. unannounced inspections, posting requirements, unusual incident reports, on-limits vs. off-limit areas, licensing file management, fire drills, 80% supervision, 100% supervision, fingerprint clearances, advertising, mandated reporting, and best practices.

LPA consulted the applicant regarding personal rights. Applicant understands that corporal, physical and/or unusual forms of punishment is never allowed toward day care children or their own children during day care hours.

LPA discussed the Immunization Regulations SB 792, the requirement that all individuals working or volunteering at a licensed Child Care Home must have vaccinations against, Pertussis, Measles and Influenza. Proof of required vaccines have been obtained from the Applicant.

LPA explained the requirement of AB1207 Mandated Reporter training. LPA explained that training must be completed once every two years. LPA observed that Mandated Reporter training certificate is on file and was taken on 01/08/2022.

Applicant understands that if anyone else works with the children, must also obtain the following: EMSA certified CPR and first aid training if left alone with the day-care children, and immunization for Measles, Pertussis and Influenza, and complete AB1207 Mandated Reporter Training.

Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

Applicant understands that her FCCH license is not transferable, and once licensed, Applicant must live in the home and be present for 80% of the operating hours. LPA explained to Applicant that if she moves and wants to continue to provide care, she must submit a change of location application, and have the new home inspected again.

REPORT CONTINUED ON NEXT PAGE

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: ALUBAYDI, IMAN
FACILITY NUMBER: 343624236
VISIT DATE: 04/06/2022
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Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the written Unusual Incident Report (LIC 624) shall be submitted within seven days to remain in compliance. Applicant understands that if she wants to make any changes to on or off limit areas in the home, she must notify licensing and LPA must do an inspection BEFORE children are allowed in the areas.

LPA provided Applicant with Safe Sleep PIN 20-24-CCP, reviewed Infant Individual Sleeping Plan (LIC 9227) for children under 12 months, and sleep logs for the children under two years of age. LPA discussed current COVID-19 child care guidelines with Applicant.

Applicant understands that children’s records are to be maintained according to Title 22 Regulations and be accessible to licensing for up to three years. Licensee understands that her License, Emergency Disaster Plan, and the Parents Rights Poster must be posted in the home.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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


REPORT CONTINUED ON NEXT PAGE
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ALUBAYDI, IMAN
FACILITY NUMBER: 343624236
VISIT DATE: 04/06/2022
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LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted

Entrance Checklist was provided to the applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Items needed prior to licensure:

· Applicant’s fingerprint clearance completed

After Applicant’s fingerprint clearance is completed, facility will be approved for a Large Family Child Care home license to serve a maximum capacity (when there is an assistant present): 12 children, no more than four infants or a capacity of 14 with no more than three infants and one child in kindergarten or elementary school and one child at least age six.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the applicant.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4