344500451-10-8-2021-53-CC-FDIZ-C7LPZF-20211008114527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 344500451
Report Date: 10/08/2021
Date Signed: 10/08/2021 11:45:35 AM

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:	SHAHID, FARAH		FACILITY NUMBER:	344500451
ADMINISTRATOR:	SHAHID, FARAH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 468-4971
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	14	CENSUS: 0	DATE:	10/08/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Farah Shahid		TIME COMPLETED:	12:00 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) Fabiola Diaz conducted a pre-licensing inspection with applicant, Farah Shahid. Applicant's husband was present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. A health and safety inspection was conducted inside and out. The home is a two story home with 3 bedrooms, 3.5 bathrooms, a kitchen, a nook, a living room, a gather room, dining area, a day care room, a laundry room, and a garage. The off-limit areas in the home are entire upstairs, garage, and sides of backyard. The home has stairs barricaded according to Title 22. LPA advised the applicant that if there are ever any poisons at the home, all poisons must be locked with a key lock or combination lock. LPA observed the home to provide safe toys, play equipment and materials for the day care children. Toxic and hazardous items are inaccessible to children. LPA observed a functioning dual smoke detector and carbon monoxide detector. LPA observed a 2A-10B-C fire extinguisher in the home. Applicant stated there are no weapons in the home. Current EMSA approved pediatric CPR and First Aid training was verified and expires 3/13/23. Applicant's CA AB1207 Mandated Reporter training expires 1/14/22. Applicant completed the 8 hour Preventative Health and Safety Training on July 28, 2021. A fire clearance was granted on 9/27/2021 by the Cosumnes Community Services District FD. Page 1. Report Continues on LIC 809-C...

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

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 3

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: SHAHID, FARAH	FACILITY NUMBER: 344500451
	VISIT DATE: 10/08/2021

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
26
27
28
29
30
31
32

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
This facility evaluation report was reviewed and discussed with the applicant. Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Applicant was encouraged to visit the department website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes. LPA provided and discussed the Safe Sleep in Child Care Regulations (and provided a copy) and the Effects of Lead Brochure. LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list. childcareadvocatesprogram@dss.ca.gov.

Applicant was encouraged to maintain supervision at all times. LPA discussed requirements for staff, adult assistants, and adults living in the home. LPA discussed the new 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. LPA observed proof of applicant's immunization in the facility file. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed. Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

Page 2. Report Continues on LIC 809-C...

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: SHAHID, FARAH	FACILITY NUMBER: 344500451
	VISIT DATE: 10/08/2021

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
26
27
28
29
30
31
32

Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected.

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 Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Applicant understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area. 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.

Today 10/8/21, the facility was approved for a Large Family Child Care License to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without assistant, the ratios revert to those for small family childcare home.

An exit interview was conducted. No deficiencies were cited on today's date. A Notice of Site visit was provided.

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3