434406410-8-4-2021-52-CC-MESA-C5KTLK-20210804144941

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434406410
Report Date: 08/04/2021
Date Signed: 08/04/2021 02:49:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	SALIM, FAUZIA		FACILITY NUMBER:	434406410
ADMINISTRATOR:	SALIM, FAUZIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 946-6023
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	14	CENSUS: 3	DATE:	08/04/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Fauzia Salim		TIME COMPLETED:	03:00 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	On Wednesday, August 4, 2021 at 1:35 PM, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced Required 1 Year visit. LPA met with the Licensee and explained the nature of site visit. Present on this visit were Licensee's spouse, 2 infant and 1 preschool child. Facility operates from Monday to Friday 8am to 5pm. LPA toured the facility to conduct a health and safety inspection. The home is a two story home. The home is neat and clean with heating and ventilation for safety and comfort. The On Limit Areas are the living room, dining room, kitchen, child care room, bathroom where the laundry area is also located and the backyard. The backyard play area is completely fenced. The Off Limit Areas are the entire second floor, front yard and the garage which will be inaccessible to children in care by closed and or locked doors and or a fence with visual supervision. There are gates located on the bottom of the stairs. The designated isolation area for a child who becomes ill while in care is the living room. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector and working telephone. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills. Licensee owns the house and does not carry childcare liability insurance or a bond and maintain the signed form LIC 282 AFFIDAVIT REGARDING LIABILITY INSURANCE. SEE 809 C.....

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel Estoesta	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SALIM, FAUZIA	FACILITY NUMBER: 434406410
	VISIT DATE: 08/04/2021

NARRATIVE

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The licensee CPR and First Aid certificate and expires on November 2021. The licensee completed the Mandated Reporter General Training and Child Care Providers training online at https://mandatedreporterca.com/ and advised the Licensee that it is renewed every 2 years. Licensees have records of Measles and Pertussis immunization, Influenza vaccination and TB clearance. LPA reminded Licensee that only the Influenza vaccination can be decline with a written declination.

Facility roster of children was reviewed. Children’s files were reviewed, which included records of receipt for Parents' Rights Notice, Identification and Emergency Information, Consent for Emergency Medical Treatment form, and Immunization. The licensee is in ratio today.

Licensee stated that she does transport children at this time. Licensee has a current and valid Driver License. Licensee understands that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children in care shall be maintained in safe operating conditions and all vehicle occupants must be secured in an appropriate restraint system.

Individual Medical Services (IMS) policy was discussed. 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: https://www.ada.gov/childqanda.htm.

Licensee is reminded that all assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. To file a complaint regarding a state licensed community care facility or child care facility, call Community Care Licensing Division Complaint Hotline 1-844-538-8766 or email letusno@dss.ca.gov.

SEE 809 C.....

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel Estoesta	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SALIM, FAUZIA	FACILITY NUMBER: 434406410
	VISIT DATE: 08/04/2021

NARRATIVE

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The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility.

LPA Estoesta discussed, provided copies of Guardian, New Safe Sleep Brochure, Lead Poisoning Facts Flyer and California Child Safety Seat Law to the licensee. For more information, please follow the links https://cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep, https://cdss.ca.gov/inforesources/child-care-licensing/water-testing-information and https://www.chp.ca.gov/Programs-Services/Programs/Child-Safety-Seats.

Licensee is encouraged to visit the Department’s website to access resources for Providers, Title 22 Regulations, online option to pay Annual License fee, all forms can be downloaded, Child Care Resource & Referral Network (R&Rs) and more information at https://cdss.ca.gov/inforesources/child-care-licensing. This website link https://ccld.childcarevideos.org/ includes videos that explain licensing topics relevant to families and licensed child care providers.

Effective August 1, 2003 California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail.

For licensing updates, advised Licensee to email childcareadvocatesprogram@dss.ca.gov and request to be added to the email list. There are no deficiencies cited on this visit. This report shall remain on file for 3 years. A copy of the appeal rights was provided. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel Estoesta	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC809 (FAS) - (06/04)

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