434409517-9-14-2022-07-CC-MMOO-CJ9NLL-20220914103344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409517
Report Date: 09/14/2022
Date Signed: 09/14/2022 05:07:39 PM

Document Has Been Signed on 09/14/2022 05:07 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, AMINA		FACILITY NUMBER:	434409517
ADMINISTRATOR:	SHAMS, AMINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 379-5164
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95130
CAPACITY:	14	CENSUS: 0	DATE:	09/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Amina Shams		TIME COMPLETED:	10:45 AM

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	Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Required - 1 Year Inspection. LPA met with Licensee, Amina Shams, and explained to her the purpose of today's visit. There were no children present in the home. LPA observed all required posted materials. Days and hours of operation for the facility are Monday – Friday, 8:00 AM to 6:00 PM. Adult residing in the home: Licensee. 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. Licensee has current children's roster and copy was obtained during the inspection. LPA observed: fully charged 3A40BC fire extinguisher, functioning smoke detector, working carbon monoxide detector, and barricaded fireplace. Licensee states that there are no weapons in the home. 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. 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 page:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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: 09/14/2022

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LPA toured the home both indoor and outdoor. Off limit areas in the home: two bedrooms, master bathroom, kitchen, family room, and dining area. The children's bathroom is clean, sanitary, and operable. Sufficient toys and play equipment for the children were observed. 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 reminded 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.

One (1) child's file was reviewed. Licensee's Mandated Reporter Training certificate expires on February 20, 2024. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years, website: www.mandatedreporterca.com. Licensee has current Pediatric CPR/First Aid certification with an expiration date of January 15, 2024.

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/process

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

As a result of today's inspection, there were no deficiencies cited.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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