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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409517
Report Date: 03/16/2022
Date Signed: 03/16/2022 02:18:33 PM


Document Has Been Signed on 03/16/2022 02:18 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: 0DATE:
03/16/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Amina ShamsTIME COMPLETED:
02:25 PM
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Licensing Program Manager (LPM), Joel Segura, and Licensing Program Analyst (LPA), Marilou Monico, met with Licensee, Amina Shams, at the San Jose Regional Office today for a scheduled Informal Meeting. The purpose of today's meeting is to discuss the following issue:

This informal conference is a direct result of recent type A citation:
01/26/22 - Section 101223(a)(2)- Personal Rights - A child's personal rights were violated when a child picked up a hot cup of tea on the table which burned her upper right arm and upper chest area.

The Plan of Correction (POC) for Personal Rights was received by Community Care Licensing (CCL) on January 26, 2022 via fax. Licensee made a spot on the kitchen cabinet where she will leave the hot tea cup, by the door where she will stand by the childcare and finish her tea cup. The cup will not be brought to the childcare area ever again.

Licensee agreed to enroll in Health and Safety or Parenting class. Proof of completion to be sent to CCL by April 29, 2022.

LPM explained to Licensee that if there are continued deficiencies cited for the issue noted on this report, the Facility may be referred to legal department for possible administrative action, which could include revocation of the Facility license. The Facility will be monitored for the next 12 months to ensure that the Facility is in compliance with the Department regulations.



Assembly Bill 633 (Child Care Parent Notification Requirements) and Acknowledgement of Receipt of Licensing Report (LIC9224) was also explained and provided to Licensee during today’s meeting.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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