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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405191
Report Date: 12/09/2022
Date Signed: 12/13/2022 03:02:51 PM


Document Has Been Signed on 12/13/2022 03:02 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:HASSEN, MOMINAFACILITY NUMBER:
434405191
ADMINISTRATOR:MOMINA HASSENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 363-1881
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:14CENSUS: 6DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Wilson, SharonTIME COMPLETED:
02:00 PM
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On this day Licensing Program Analysts (LPA/s) Almaraz conducted an unannounced annual inspection, of a large family childcare home (capacity of 14). Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPA/s met with Assistants Wilson, Sharon and Ibrahim, Fetiya. Present during the inspection, were assistants Wilson, Ibrahim and six children, including two infants over 12 months old, and four preschoolers. There are currently nine children enrolled.

The hours of operation are from 6:00 AM to 5:30 PM, Monday thru Friday. There are 3 adults residing in the home (criminal record clearances on file). Licensee and spouse Heyi, Nigussie, and assistant Ibrahim, Fetiya. Per assistants Licensee is out of the country until approximately January 14th, 2022 and has been out of the country about one week.

Physical Plant: This is a single-story dwelling which consists of 3 bedrooms and two lavatories. LPA/s inspected the indoor and outdoor areas of the home today. Per assistant Off limit areas in the home are as follows: The 3 bedrooms, Living room, dinning room, add on room, laundry room. The day care area is in a converted garage area adjacent to the home. This area is made inaccessible with a locked door. There is an exit door in the event of an emergency. Off limit areas outside the home are as follows: Four storage sheds, the right yard, gated, three of the sheds did not have locks, based on LPA observation, they did not have items that posed a threat to the children in care. LPA checked the fence and found an area where the children in care can fit through. Assistant called spouse and LPA explain this, spouse said that this will be fixed before the conclusion of the inspection. LPA discussed a citation if this cannot be fixed before the inspection is over and that the backyard must be made off limits in this case. LPA also discussed the locks that should be placed on sheds for best practice. The front yard is safety complaint. The children use the back yard for outdoor activities.

During this inspection, the following was noted: At 11:30 AM, LPA/s began tour through the interior of the home. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and central heating for safety and comfort. Pg. 1/6
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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 7


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: 12/09/2022
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Kitchen: All kitchen areas/food preparation and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. LPA checked that water and refrigerator temperatures in standard condition. Per assistant waste will be discarded immediately after each meal.

Food: Per assistant meals are prepared at the facility daily. Licensee provides breakfast, lunch and AM/PM snacks. LPA and assistant discussed that food brought from home should be labeled. Per assistant there are no children enrolled with allergies. LPA has advised assistant to keep an allergy list in the kitchen area, should there be any children enrolled with allergies. LPA and assistant discussed having the 5 food components kept on site.

All areas identified on the facility sketch were inspected. Areas that are accessible to day-care children are the converted playroom.

The assistant understands that areas that are off-limits must remain inaccessible to the children in care during operating hours. The assistant does understand that licensing staff may have access to off-limit areas during inspection visit if necessary.

Lavatories: There is one lavatory that is accessible to the children in care. There is a change table with an appropriate change pad. Assistant states that potty training is provided at facility.



Outdoor play: The back yard has adequate shade in the play yard.

Hazards: LPA did not observe any hazards inside the home. LPA asked to be shown the electrical outlets in the areas used by the children and observed to be covered. Detergents, cleaning compounds, medicines, sharp objects, and hazardous items that can pose a danger to children was observed out of reach or locked from the children in care. The assistant states that there are no poisons in the home. The assistant was advised that any poisons must be locked with a key or combination lock. LPA also observed appropriate equipment, toys, and games for children. Per assistant there are no known firearms in the home. There are no bodies of water inside or outside of the home.

Fire & Safety: Carbon monoxide detectors and smoke detectors are working and present in the facility. There is a fire extinguisher, size 2A10BC, fully serviced; Last fire drill 11/04/2022, assistant understands a fire drill is to be completed at least every six months. There is fireplace in the home, in an inaccessible area. There were no wall heaters observed in the home. Per assistant there is no smoking in the home.

Facility Records: Assistant Wilson has CPR and First Aid, valid until 03/25/2022, for assistant Ibrahim valid thru 10/22/2024. Assistant Wilson has record of MMR & Tdap vaccinations, opt out for flu vaccine. Assistants and licensee do not have record of mandated reporter training. Pg. 2/6

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: 12/09/2022
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Assistant Ibrahim is currently working on Mandated Reporter Training; however, the primary language is Amharic, which is not available. Assistant Wilson understands this must be renewed every two years. LPA/s discussed forms the requirements for staff and children's files. LPA issued an LIC 857 and 859, review of children and staff files.

Sign in and out: Per assistant there is a sign in/sign out system. LPA informed assistant that this is not mandatory for a FCCH.



Waivers: There are no waivers or requests on file.

Medical & First Aid Supplies: There is a first aid kit in the home, kept in the day care area. LPA and assistant discussed that medication is only to be administered to a child when accompanied with a doctor's note, parent plan, authorizations are to be completed monthly. The medication shall be kept in a locked cabinet or in a locked box in refrigerator if needed and/or in emergency backpack when children outside (at least six feet high) which is stored out of reach of children. LPA and assistant discussed that medication, and first aid supplies shall be accessible to staff at all times during care.


Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

Matts and cots: Per assistant napping is done at this facility. LPA observed matts for napping in a safe condition with no exposed foam. Constructed of material at least 3/4 inch thick. Covered with vinyl or similar material that can be wiped. Designed so that the sleeping side can be distinguished from the floor side. Per assistant cots are wiped weekly with a detergent, disinfectant or when soiled or wet. Each matt observed to be equipped with a sheet and/or blanket to cover the child. Per assistant bedding is not shared. Per assistant sheets/blankets shall be laundered when soiled. LPA observed bedding is individually stored so that each child's bedding is identifiable, and assistant states no child's used bedding shall meet other bedding. Bedding is washed on site at facility weekly. Pg. 3/6

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: 12/09/2022
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Safe sleep: LPA/s observed and inspected sleeping equipment for infants. LPA/s observed cribs for each infant who is unable to climb out of the play yard. All equipment meets the US Consumer Product Safety Commission safety standards. Please see www.safekid.org for a list of any recalled products. LPA/s observed that cribs are free from loose articles and objects. There are no objects hanging above or attached to the side of the cribs. LPA reminded assistant that play yards shall not hinder the entrance or exit to and from the space children are sleeping in. LPA observed mattresses to be firm and covered with a fitted sheet that is appropriate to the mattress size.

Each infant must have their individual bedding and is to be washed daily or as required. Bedding must be replaced when wet or soiled and is placed in an area inaccessible to infants. Pacifiers must not be attached to anything. Assistant was advised that infants shall not be swaddled while in care and all infants up to 12 months should be placed on their back for sleeping. LIC 9227 (Individual Sleeping Plan) for infants up to 12 months was discussed. Title 22 Regulation Section 102425(j) Infant Safe Sleep was discussed with the assistant, including but not limited to documentation that shall be maintained. A review of PIN 20-24-CCP Recently approved Safe Sleep Regulations in Effect was discuss and a copy was provided to the Licensee during this inspection. LPA observed sleep log is kept for infants in care. Assistants physically check on infants at least every 15 minutes and documents the following: 1. Breathing, Sleep position, signs of distress.


LPA advised assistant to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. For commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Postings: LPA and assistant discussed the required postings, including, Parent’s Rights Poster (with complaint Hotline), an emergency disaster plan, the license and any notice of site visits. LPA observed postings.

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/inspection-process Pg. 4/6

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: 12/09/2022
NARRATIVE
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Assistant was reminded that all adults 18 and over, 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 Child Care Center. 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.

SB792 (Immunization Requirements for Staff and Employees) was discussed with the facility representative.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a childcare facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers


The following was discussed:

-Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalty will be assessed if not in compliance.

-In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated with the facility license.

-A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

-Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated.

-The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

-Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes, and/or if you move from your home.

-Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. (use LIC624B for written report).

-Fire and safety drills must be performed every six months and documented for review by the Department.

-Smoking is prohibited in a family childcare home.

-Children and Staff records must be maintained and updated as needed and must be available for review by the Department. Pg. 5/6

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: 12/09/2022
NARRATIVE
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 No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines, and any other item that falls into that category are not permitted in the facility.

-All adults living and working in the home shall be made aware of the Department's right to inspection authority, which includes but is not limited to the right to enter the home when children are being cared for, interview children and adults, and review documentation.

- Licensees shall reveal each facility license number in all advertisements, publications, or announcements with the intent to attract clients.

- Emergency Disaster Plan, Parent’s Rights Poster, and the Facility License are required to be posted.

Per assistant, it is not known if the licensee carries liability insurance or a bond in accordance with the standard established by the Family Child Care statute. The law requires a Family Child Care provider to carry liability insurance or bond in the amount of $300,000 annually or to maintain the signed statement in the facility file. Signed statements (LIC282) noted on children’s files. LPA and licensee discussed that the home insurance may cover this. LPA consulted and explained Child Abuse Reporting, Effects of Lead Exposure Flyer, Updated Patent’s Rights Poster with Complaint Hotline information, Capacity Handout (Small & Large) was provided during this inspection. LPA advised how to access forms, regulations and quarterly updates, and Provider Information Notices (PIN) on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms: Children forms/records, Facility forms/records, facility forms/ records, and Information to be posted in the Family Child Care Home.

During this inspection, Licensing staff consulted with assistant regarding COVID-19 health and safety guidelines on this date, assistant was provided CCP- COVID 19 Self- Assessment and forms to post. Per assistant, the following safety precautionary measures will be taken during the pickup and drop off of children: Daily health checks and screening upon entry will be conducted by Licensee and assistant.

LPA has advised the following for best practice. 1. Maintain an allergy list. 2. Do not use cribs for storage. 3. Freezer in childcare area to be repaired. There is access to a freezer in the main home. 4. Keep infant area free of clutter. 5. Keep locks on shed during day care hours. 6. Check fencing for repairs regularly. There are two B citations being issued for the following: 1. Incomplete staff, including Mandated Reporter Training for assistant Wilson and licensee, proof of immunization's in accordance with Chapter 1, Division 12, Title 22 of the California Code of Regulation. The fence was fixed prior to the conclusion of this inspection and the locks were placed on the shed. The assistants understand to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years. An exit interview conducted, and report was reviewed with licensee.

NOTICE OF SITE VISIT ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS. Pg. 6/6

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 12/13/2022 03:02 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: HASSEN, MOMINA
FACILITY NUMBER: 434405191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2023
Plan of Correction
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Licensee and Assistant will submit Mandated Reporter Training to LPA on or before 01/06/2022.Licensee out of country and may need longer to complete.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

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 in which poses/posed a potential health, safety or personal rights risk to persons in care. Not all staff files have record of immunizations.
POC Due Date: 01/06/2023
Plan of Correction
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Licensee must submit proof of immunizations for all staff to LPA via email on or before 01/06/2023.
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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7