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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409517
Report Date: 09/18/2019
Date Signed: 09/18/2019 10:56:32 AM

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:SHAMS, AMINAFACILITY NUMBER:
434409517
ADMINISTRATOR:SHAMS, AMINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 379-5164
CITY:SAN JOSESTATE: CAZIP CODE:
95130
CAPACITY:14CENSUS: 6DATE:
09/18/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Amina ShamsTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Marilou Monico, made an unannounced annual random inspection. LPA met with Licensee, Amina Shams, and explained the nature of today's visit. Also present in the were home 6 daycare children including 3 infants and 3 preschool age. Days and hours of operation are Monday to Friday from 7:00 AM to 6:00 PM. Licensee is the only adult residing in the home.

LPA toured the home both indoor and outdoor. LPA observed sufficient materials, toys, and play equipment for the day care children. There is a fully charged 3A40BC fire extinguisher, working smoke detector, functioning carbon monoxide detector, barricaded fireplace, and no bodies of water. Off limit areas in the home: two bedrooms, master bathroom, kitchen, family room, and dining area. Off limit areas outside the home: fenced off area of the backyard. Medications, cleaning compounds, sharp objects, and other similar items are stored out of reach of children. Per licensee, there are no weapons in the home. Six children's files were reviewed. Licensee maintains a current children's roster and fire drill log. LPA obtained copies of children's roster. Licensee has current CPR/First Aid certifications with an expiration date of February 10, 2020. The home has a working telephone which is (408) 379-5164.

LPA discussed with licensee: Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years, and AB 633. Licensing forms, Title 22 regulations, can be obtained through the internet at ww.ccld.ca.gov. Mandated Reporter Training can be accessed at www.mandatedreporterca.com.

Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility.

(REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 09/18/19):
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
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 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SHAMS, AMINA
FACILITY NUMBER: 434409517
VISIT DATE: 09/18/2019
NARRATIVE
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(CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 09/18/19):

Incidental Medical Services (IMS) policy was discussed. Licensee states she is not providing IMS 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 (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.

A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemption.

As a result of this inspection, deficiency was cited on the following page:



NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHAMS, AMINA
FACILITY NUMBER: 434409517
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2019
Section Cited

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MANDATED REPORTER TRAINING - On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training and shall complete renewal every two years following the date on which he or she completed the initial mandated reporter training.
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This requirement is not met as evidenced by: LPA observed that Licensee is missing proof that she completed Mandated Reporter Training. This poses a potential risk to health and safety 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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3