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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405191
Report Date: 12/02/2019
Date Signed: 12/02/2019 05:30:50 PM

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:HASSEN, MOMINAFACILITY NUMBER:
434405191
ADMINISTRATOR:MOMINA HASSENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 363-1881
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:14CENSUS: 9DATE:
12/02/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Momina HassenTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dung Mac arrived at the facility at 1:10pm. Licensee went to pick up her daughter. LPA observed Assistant Sharon Wilson was in the home with nine daycare children. Licensee returned home at 1:30pm. LPA met with Momina Hassen, Licensee, and explained the purpose of today’s inspection. LPA observed Licensee's daughter age 16, and nine daycare children of whom were two infants and seven preschoolers in care.

Days and hours of operation are: Monday-Friday 6:00am-5:30pm. LPA toured the home both inside and out. The entire home is off limit. Garage was converted and was approved for daycare. LPA observed a fireplace is screened. Backyard is fenced and is used as outdoor play area. LPA observed three sheds are locked. LPA observed that there are no bodies of water.

LPA observed a fully charged fire extinguisher, working smoke detector and carbon monoxide. Licensee stated that there are no weapons in the home. Cleaning products, toxic, medications, and sharp objects were inaccessible to children. The facility is clean, orderly, and safe for the day care children. LPA observed sufficient materials, toys, and play equipment for the day care children.

Licensee stated that she does not transport children. The last fire/disaster drill was conducted on 11/4/19. LPA reviewed the Child Care Facility Roster. Nine children's files were reviewed. LPA observed all children's files did not have the Consent for Medical Treatment (LIC 627) and Records of immunization (PM 286).


Continued on Page #2
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2019
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 5
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: HASSEN, MOMINA
FACILITY NUMBER: 434405191
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2020
Section Cited

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Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home. This requirement is not met as evidenced by Assistant did not have
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a copy of TB clearance which poses a potential Health, Safety, and Personal risks to daycare children.
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Type B
01/06/2020
Section Cited

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 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. This
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requirement is not met as requirement is not not met as evidenced by Licensee and Assistant did not have copies immunization records which poses a potential Health, Safety, or Personal Rights risks to daycare children.
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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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: HASSEN, MOMINA
FACILITY NUMBER: 434405191
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2019
Section Cited

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Immunizations: licensee shall document each child's immunizations [..] and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as
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evidenced by Licensee did not document immunizations (PM 286) for each child which poses a potential Health, Safety, or Personal Rights risks to daycare children.
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Type B
12/16/2019
Section Cited

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Operation of a Family Child Care Home: [...] the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement is not met as evidenced by Licensee
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did not maintain the Consent of Medical Treatment form (LIC 627)in each child's file which poses a potential Health, Safety, or Personal Rights risks to daycare children.
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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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: HASSEN, MOMINA
FACILITY NUMBER: 434405191
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2019
Section Cited

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Staffing Ratio & Capacity: If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care.
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This requirement is not met as evidenced by Assistant was in the home with nine daycare children which poses an immediate Health, Safety, or Personal risks to daycare children.
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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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: HASSEN, MOMINA
FACILITY NUMBER: 434405191
VISIT DATE: 12/02/2019
NARRATIVE
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Continued from Page #1

Licensee's file was reviewed. Licensee did not have a record of immunization against Pertussis. Licensee's Pediatric CPR & First Aid certification expired 4/2019. Licensee's Mandated Reporter training expires 1/28/2020. LPA reminded Licensee that the Mandated Reporter Training needs to be renewed every two years. Licensee was provided the Mandated Reporter Training website http://mandatedreporterca.com.

Assistants' file was reviewed. LPA observed records of immunization, a copy of Tuberculosis clearance, and a copy of certificate of Mandated Reporter training are not on file. Assistant's First Aid/CPR certificate expires 6/2021.

Adults who reside in the home are Licensee and Licensee's spouse. They have Clearances for Tuberculosis, and Criminal Background and Child Abuse Index Checks. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children.

LPA provided a copy of the “Lead Poisoning Facts Information Flyer”, "Car Seat Law", and "Safe Sleep" Information to Licensee. Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing updates and regulations.

Type A and Type B deficiencies were cited today. An exit interview was conducted. Appeal Rights were given to Licensee. Notice of Site Visit was given to Licensee and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5