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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004035
Report Date: 11/15/2022
Date Signed: 11/15/2022 01:44:32 PM


Document Has Been Signed on 11/15/2022 01:44 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/15/2022 01:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

NARRATIVE
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Licensing Program Analyst, LPA Yee conducted a follow-up inspection today. Present at the facility are two helpers and 8 children (5 infants). One infant is almost 2 years old. The licensee was not present during the inspection. Today LPA reviewed two staff files and 8 children's records.

1) S1 is missing AB1207 "Child Care Providers certificate" and LIC9052 "Employee Rights".
S2 is missing TB, TDAP, and LIC9052. The plan of correction is extended to 11/28.

2) C1: missing LIC627 "consent for emergency treatment"
C6: missing LIC627 "consent for emergency treatment", Immunization
C7: LIC700 "ID, emergency info" authorized representative signature is missing
C8 : LIC700, "ID emergency info" correct form was not used. Missing immunization. The plan of correction is extended to 11/28.

3) emergency drill was not able to verify. The plan of correction is extended to 11/28

4) Infant sleep chart was verified today. Citation cited on 10/26 has been corrected.

5) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] was verified today. Citation cited on 10/26 has been corrected.

FCCH capacity worksheet was explained and provided.

See next page for type B citation.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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Document Has Been Signed on 11/15/2022 01:38 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MEKKY, RASHA A.
FACILITY NUMBER: 384004035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2022
Section Cited

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102416.5(a) Staffing Ratio and Capacity. (a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement was not met as evidenced by:
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Based on the physical inspection and record review, LPA confirmed licensee operated the day-care at over capacity. This poses a potential health and safety risk to children in care.
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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: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
LIC809 (FAS) - (06/04)
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