430756975-12-7-2022-07-CC-MMOO-CLW2JW-20221207162703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430756975
Report Date: 12/07/2022
Date Signed: 12/07/2022 04:27:15 PM

Document Has Been Signed on 12/07/2022 04:27 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	SAMAAN, SAYDE & SAMIR		FACILITY NUMBER:	430756975
ADMINISTRATOR:	SAMAAN, SAYDE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 985-9055
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	14	CENSUS: 3	DATE:	12/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:58 PM
MET WITH:	Sayde Samaan		TIME COMPLETED:	04:40 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), Marilou Monico, met with Licensee, Sayde Samaan, for an unannounced Required - 1 Year Inspection. Three (3) infants were also present in the home. All required posted materials were posted by the door. The daycare is open Monday thru Friday from 7:00 AM to 5:30 PM. There are no active waivers or exceptions for this facility. Per Licensee, there are three (3) adults residing in the home: herself, her husband, and her son. LPA observed a current children's roster (LIC9040). Copy of children's roster was obtained during the inspection. Fire/disaster drill was conducted on September 23, 2022. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke and carbon monoxide detectors, and barricaded fireplace. Sayde states that there are no weapons or firearms in the home. Incidental Medical Services (IMS) policy was discussed. Licensee states that she is not planning to administer any medication at this time. 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 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 LPA reminded licensee 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. Continuation on next page:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SAMAAN, SAYDE & SAMIR	FACILITY NUMBER: 430756975
	VISIT DATE: 12/07/2022

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Off limit areas in the home: master bedroom, master bathroom, and garage LPA observed that the home is clean. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 985-9055. Off limit areas outside the home: hot tub/spa area. LPA observed a hot tub/spa in the backyard with a fence that is at least five feet in height and a locked gate.

Three (3) children’s files were reviewed during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), Individual Infant Sleeping Plan (LIC 9227), and Immunization Records (PM 286/CDPH 286).

Sayde's Mandated Reporter Training expires on May 4, 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years. Licensees, Sayde and Samir, have current Pediatric CPR/First Aid certifications with an expiration date of January 8, 2024.

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

Exit interview conducted and report was reviewed with Sayde Samaan, Licensee.

As a result of today's inspection, there were no deficiencies cited.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

LIC809 (FAS) - (06/04)

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