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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500204
Report Date: 02/10/2022
Date Signed: 02/10/2022 02:01:20 PM


Document Has Been Signed on 02/10/2022 02:01 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:AHMED, SHABANA & MUSTAFA, HUMAFACILITY NUMBER:
344500204
ADMINISTRATOR:AHMED, SHABANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 271-7575
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:14CENSUS: 3DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Huma Mustafa, LicenseeTIME COMPLETED:
02:10 PM
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On February 10, 2022, at 10:15 am Licensing Program Analyst's (LPA's) Salene Mayberry and Christopher Jackson met with the licensee, Huma Mustafa, for the purpose of an unannounced annual random inspection. Facility hours of operation are 6:30 am to 6:00 pm Monday through Friday. A review of the Facility Personnel Summary shows that all adults living and working in the home have criminal record clearances on file with Licensing Office. Licensee stated that no new residents moved into the home since licensure. Capacity specified on the license was met on today’s inspection. LPAs observed three children in care with Licensee. Present in the facility was licensee Huma Mustafa.

A health and safety inspection was conducted in all areas accessible to children in care. Off limit areas are: bedroom #1, bedroom #3, kitchen, laundry room and garage. Upon entry, LPAs observed the posting of the facility license, Emergency Disaster Plan, Earthquake Preparedness Checklist and Notification of Parent Rights. Facility maintains a working phone, 2A10BC fire extinguisher, and functioning smoke/carbon monoxide detector. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. Toxic and hazardous items are inaccessible to children. The fireplace in the home is appropriately barricaded to prevent access by children and outdoor play space is fenced.

At 10:45 AM LPAs requested facility records from Licensee, which include children and staff files. Six of the children’s files and two of staff files were reviewed. All required forms for the children in care are complete and maintained in the file. LPAs reviewed staff files and licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current in person EMSA CPR and First Aid certification was verified and expires 02/2024 and AB 1207 Mandated Reporter Training was verified and expired 06/19/2021. LPAs discussed the requirement to renew the mandated reporter training every two years. LPAs provided the mandated reporter training website: www.mandatedreporterca.gov. LPAs observed a current roster and fire drills are conducted at least once every six months.

Report continues on 809-C.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Salene MayberryTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022
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: AHMED, SHABANA & MUSTAFA, HUMA
FACILITY NUMBER: 344500204
VISIT DATE: 02/10/2022
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LPAs verified the annual fees are current. Licensee was reminded that all adults 18 and over living or working in the home, 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.

Incidental Medical Services (IMS) policy was discussed. 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



LPAs discussed the safe sleep regulations with Huma Mustafa 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. LPAs also informed Licensee 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.


A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Huma Mustafa.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Salene MayberryTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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