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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
376625371
Report Date:
03/10/2023
Date Signed:
03/10/2023 01:56:53 PM
Document Has Been Signed on
03/10/2023 01:56 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
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
HIRSI, LUL FAMILY CHILD CARE
FACILITY NUMBER:
376625371
ADMINISTRATOR:
LUL HIRSI
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(858) 717-4555
CITY:
SAN DIEGO
STATE:
CA
ZIP CODE:
92115
CAPACITY:
14
CENSUS:
2
DATE:
03/10/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:13 PM
MET WITH:
Lul Hirsi
TIME COMPLETED:
02:15 PM
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On 3/10/2023 @ 12:13PM, LPA Nancy Diaz conducted an unannounced inspection. Upon arrival, LPA was greeted at the door and allowed entry by Lucky Egal. There were 2 infants observed sleeping in play pens. Ms. Egal stated that Mrs. Hirsi stepped out to the grocery store. Licensee's daughter, Fartun Ali arrived shortly. She assisted in translating this inspection in Somali A tour of the home was conducted. The following areas are accessible to children living room, kitchen, family room . Facility operates 7 days/24 hours. The licensee was present in the home to ensure that all children are supervised at all times. Facility is within capacity and did not exceed the capacity specified on the license.
There were no bodies of water observed within the premises. Licensee stated that she does not maintain weapons in the home.
Detergents and cleaning compounds were observed accessible to children.
Fire extinguisher and smoke detectors meet State Fire Marshall standards. The carbon monoxide detector present in the home meet the standards established in Chapter 8 of Part 2, Division 12. Home is kept clean and orderly with heating and ventilation for safety and comfort. Licensee provide safe toys, play equipment and materials. The home maintains a working telephone service.
There is a play pen for each infant who is unable to climb out. The play pen was observed with stuffed toy, blankets and pillows. There are no objects hanging above or attached to the side of the crib. Infants are not swaddled while in care. Infants are supervised while they sleep.
LPA discussed the safe sleep regulations with licensee and provided handout on safe sleep regulation that included infant sleep plan and nap log. Safe sleep log can be accessed via:
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
as an additional resource. LPA 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.
SUPERVISOR'S NAME:
Tashima Daniel
TELEPHONE:
(619) 767-2242
LICENSING EVALUATOR NAME:
Nancy Diaz
TELEPHONE:
(619) 767-2207
LICENSING EVALUATOR SIGNATURE:
DATE:
03/10/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/10/2023
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
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
HIRSI, LUL FAMILY CHILD CARE
FACILITY NUMBER:
376625371
VISIT DATE:
03/10/2023
NARRATIVE
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Car seats are only used for transportation purposes and not used for sleeping. Infants are supervised while they sleep.
The outdoor play area is fenced or supervised by the licensee. An isolation area has been designated for children who became ill during the day.
Children’s records were reviewed. Licensee maintains a copy of the emergency information card that contains all of the information specified by the regulation.
Mrs. Hirsi's file was reviewed. She is exempt from completing the mandated reporter training as her primary language is Somali.
Licensee’s CPR and First aid is valid thru October 2024..
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. Mrs. Hirsi stated that she does not maintain medications for day care children. 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
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
.
SUPERVISOR'S NAME:
Tashima Daniel
TELEPHONE:
(619) 767-2242
LICENSING EVALUATOR NAME:
Nancy Diaz
TELEPHONE:
(619) 767-2207
LICENSING EVALUATOR SIGNATURE:
DATE:
03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/10/2023
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
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
HIRSI, LUL FAMILY CHILD CARE
FACILITY NUMBER:
376625371
VISIT DATE:
03/10/2023
NARRATIVE
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Exit interview conducted and report was reviewed with facility representative, Lul Hirsi. A copy of this report, along with Appeal Rights (LIC9058), were provided. A notice of site visit was given and must remain posted for 30 days. LPA observed that the notice of site visit was posted during the inspection. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
TYPE A & B DEFICIENCIES WERE CITED.
Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
SUPERVISOR'S NAME:
Tashima Daniel
TELEPHONE:
(619) 767-2242
LICENSING EVALUATOR NAME:
Nancy Diaz
TELEPHONE:
(619) 767-2207
LICENSING EVALUATOR SIGNATURE:
DATE:
03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/10/2023
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
03/10/2023 01:56 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
HIRSI, LUL FAMILY CHILD CARE
FACILITY NUMBER:
376625371
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/10/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed 2 infants in sleeping in play pens. Observed were blankets, pillows, stuff animals and bottles in the play pen. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/10/2023
Plan of Correction
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CORRECTED TODAY. Mrs. Hirsi removed the loose articles from the play pen today.
Type B
Section Cited
CCR
102416.1(a)(6)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (6) Documentation of completion of training on preventative health practices as required by Section 102416(c).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review)], the licensee did not comply with the section cited above. Upon arrival, Lucky Egal was observed supervising 2 infants in care. She stated that Mrs. Hirsi stepped out to the grocery. She stated that she was a friend and does not work for Mrs. Hirsi. Mrs. Egal does not posses a Pediatric CPR/First aid certificate. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/24/2023
Plan of Correction
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Mrs. Hirsi stated that she will have Lucky Egal complete a Pediatric CPR and First Aid class no later than 3/24/2023. She will submit a copy of her certificate via email to Nancy.Diaz@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Tashima Daniel
TELEPHONE:
(619) 767-2242
LICENSING EVALUATOR NAME:
Nancy Diaz
TELEPHONE:
(619) 767-2207
LICENSING EVALUATOR SIGNATURE:
DATE:
03/10/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/10/2023
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
03/10/2023 01:56 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
HIRSI, LUL FAMILY CHILD CARE
FACILITY NUMBER:
376625371
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/10/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The licensee and Mrs. Egal were not able to provide this analyst a copy of the required immunization to show that they have been immunized against Pertussis, Measles and Influenza. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/24/2023
Plan of Correction
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Mrs. Hirsi shall submit a copy of her and Mrs. Egal's immunization to the department no later than 3/24/2023.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Mrs. Hirsi did not have form LIC 9227 for one infant in care (under 12 months). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/24/2023
Plan of Correction
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Mrs. Hirsi shall provide form LIC 9227 for infant's parent to fill out. She will submit a copy to the department no later than 3/24/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Tashima Daniel
TELEPHONE:
(619) 767-2242
LICENSING EVALUATOR NAME:
Nancy Diaz
TELEPHONE:
(619) 767-2207
LICENSING EVALUATOR SIGNATURE:
DATE:
03/10/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/10/2023
LIC809
(FAS) - (06/04)
Page:
5
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Document Has Been Signed on
03/10/2023 01:56 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
HIRSI, LUL FAMILY CHILD CARE
FACILITY NUMBER:
376625371
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/10/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Mrs. Hirsi did not maintain a log for the 15-minute nap check. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/17/2023
Plan of Correction
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LPA provided Mrs. Hirsi a sample nap log form. She stated that she will check on the infants when they nap and log the 15-minute checks starting today. A copy of nap log shall be submitted to the department no later than 3/17/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Tashima Daniel
TELEPHONE:
(619) 767-2242
LICENSING EVALUATOR NAME:
Nancy Diaz
TELEPHONE:
(619) 767-2207
LICENSING EVALUATOR SIGNATURE:
DATE:
03/10/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/10/2023
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
03/10/2023 01:56 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
HIRSI, LUL FAMILY CHILD CARE
FACILITY NUMBER:
376625371
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/10/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above. During a tour of the facility, LPA observed several bottles of cleaning compounds (under the kitchen and bathroom cabinets), knives in the kitchen drawer, accessible to children in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/10/2023
Plan of Correction
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CORRECTED ON THE SPOT. Mrs. Hirsi removed the cleaning compounds and knives and made them inaccessible to children. She will remind her room mate to ensure that these items are kept inaccessible to children.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Tashima Daniel
TELEPHONE:
(619) 767-2242
LICENSING EVALUATOR NAME:
Nancy Diaz
TELEPHONE:
(619) 767-2207
LICENSING EVALUATOR SIGNATURE:
DATE:
03/10/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/10/2023
LIC809
(FAS) - (06/04)
Page:
7
of
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