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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409517
Report Date: 01/26/2022
Date Signed: 02/14/2022 03:27:30 PM


Document Has Been Signed on 02/14/2022 03:27 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:SHAMS, AMINAFACILITY NUMBER:
434409517
ADMINISTRATOR:SHAMS, AMINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 379-5164
CITY:SAN JOSESTATE: CAZIP CODE:
95130
CAPACITY:14CENSUS: 2DATE:
01/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Amina ShamsTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Marilou Monico, met with Licensee, Amina Shams, for an unannounced Required - 1 Year Inspection. LPA was granted access to the home by the Licensee. Also present in the home were two infants. LPA observed all required posted materials. Days and hours of operation for the facility are Monday – Friday, 8:00 AM to 6:00 PM. There are no active waivers or exceptions for this facility. Licensee is the only adult residing in the home.

Licensee was reminded 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.

LPA observed a current facility roster (LIC9040) and fire drill log. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke detector and carbon monoxide detector, and barricaded fireplace. Amina states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. Amina states that there are no weapons or firearms in the home.

Incidental Medical Services (IMS) policy was discussed. 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

Continuation on next pages:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022
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: SHAMS, AMINA
FACILITY NUMBER: 434409517
VISIT DATE: 01/26/2022
NARRATIVE
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Indoor and outdoor areas of the facility were inspected today and observed to be clean and orderly. Off limit areas in the home: two bedrooms, master bathroom, kitchen, family room, and dining area. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the home via bottles and sippy cups. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 379-5164. Off limit areas outside the home: fenced off area of the backyard.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Two (2) 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), and Affidavit Regarding Liability Insurance. The two children are missing immunization records in the file.

Licensee states she did not complete the Mandated Reporter Training for Child Care Providers. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years, website: www.mandatedreporterca.com. Assembly Bill (AB) 633 was discussed with Licensee. Licensee has current Pediatric CPR/First Aid certification with an expiration date of January 15, 2024.

LPA reviewed with Licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Adoptions of new laws, pay annual fees etc.

Continuation on next page:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
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: SHAMS, AMINA
FACILITY NUMBER: 434409517
VISIT DATE: 01/26/2022
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Supervision of children was discussed with Licensee. Licensee states that she does not transport any day care children. LPA reminded Licensee that if she decides to transport children, children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

As a result of today's inspection, deficiencies were cited on the following page:

Exit interview conducted and report was reviewed with the Licensee, Amina Shams.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/14/2022 03:27 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: SHAMS, AMINA
FACILITY NUMBER: 434409517

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2022

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 licensee's statement, licensee did not complete the Mandated Reporter Training for Child Care Providers. This poses a potential risk to the health, safety or personal rights to children in care.
POC Due Date: 03/15/2022
Plan of Correction
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Licensee states she will submit her current Mandated Reporter Training certificate by 03/15/22.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Child #1 & #2 are missing immunization records in the file. This poses a potential risk to the health, safety or personal rights to children in care.
POC Due Date: 02/25/2022
Plan of Correction
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Licensee states she will submit proof of immunizations for the two children by 02/25/2022.

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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022
LIC809 (FAS) - (06/04)
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