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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500204
Report Date: 03/19/2020
Date Signed: 03/19/2020 01:51:05 PM

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:AHMED, SHABANA & MUSTAFA, HUMAFACILITY NUMBER:
344500204
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
03/19/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Shabana Ahmed and Huma Mustafa, TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Amy Silva met with applicants Shabana Ahmed and Huma Mustafa, for the purpose of an announced pre-licensing inspection. Applicant's days and hours of operation are Monday through Sunday 12 AM to 11:59 PM.

A health and safety inspection was conducted inside and out. The one story home has an unfenced front yard, fenced backyard, three bedrooms, two bathrooms, a living room, family room, laundry room, kitchen and garage. The off-limit areas in the home are: all bedrooms, kitchen, laundry room, and garage. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. Applicants understands that 100% supervision is required in any unfenced areas. The applicants acknowledged they must contact licensing prior to making an off-limits area on-limits and vice versa. The fireplace in the home is appropriately barricaded and will not be in use when children are present. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detectors and a 2A10BC fire extinguisher were observed in the home.

Preventative Health, current pediatric CPR and first aid training was verified and expires February 2022. Mandated Reporter training was verified and expires June 26, 2021. Applicants were encouraged to maintain supervision at all times. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed.

LPA provided and discussed the Safe Sleep in Child Care brochure, Effects of Lead Exposure brochure and the revised CDPH 286 form for the documentation of immunization's.

Report continues on 809-C.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Amy SilvaTELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: AHMED, SHABANA & MUSTAFA, HUMA
FACILITY NUMBER: 344500204
VISIT DATE: 03/19/2020
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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

This facility evaluation report was reviewed and discussed with the applicants. LIC 311D, records, postings, and reporting requirements were discussed. LPA discussed supervision, personal rights, criminal record clearances, staffing ratios and capacity, and maintaining buildings and grounds.

Applicants were encouraged to visit the Department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

Effective today 3/19/2020, License for a small family child care home is approved.
Facility is approved for a small family child care home licensed to serve a capacity of 6 children with no more than 3 infants or 4 infants only. Or with a capacity of 8 children: no more than 2 infants, 1 child in kindergarten or elementary school and 1 child at least age 6.

An exit interview was conducted and a copy of the report was provided to Applicants.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Amy SilvaTELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2020
LIC809 (FAS) - (06/04)
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