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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414604
Report Date: 09/30/2019
Date Signed: 09/30/2019 12:45:19 PM

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:MOHAMMED, FETHYAFACILITY NUMBER:
434414604
ADMINISTRATOR:MOHAMMED, FETHYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 241-3263
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:14CENSUS: 8DATE:
09/30/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Fethya MohammedTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuoc Doan conducted an unannounced Annual Inspection of the Family Day Care home. LPA met with Licensee Fethya Mohammed and explained the purpose of the inspection. Present during the inspection were eight children in care, of whom none were infant age. LPA observed that Licensee and Assistant Provider/Volunteer Najat Erraji were present to provide care and supervision to the children. Licensee stated that she understands that when she has more than 12 and up to 14 children, one child has to be enrolled in school and one child has to be at least 6 years old. Licensee also stated that she understands she must comply with the capacity requirement of a small Family Child Care Home whenever there is only one care provider home with the children.

The home’s operating days and hours are Monday through Saturday from 06:00 AM to 06:00 PM. The home maintains telephone service. The License and Notification of Parents’ Rights were observed to be posted. The home was inspected inside and out. The home was clean and orderly. LPA did not observe flies, other insects, or rodents during the inspection. The observed children’s toys, play equipment, and furniture were in good condition. There were no baby walkers at the day care. Bathroom used by children was observed to be clean and in operating condition. Food preparation area was clean.

Per Fire Clearance issued on 08/28/15, only the Living Room and hallway bathroom are allowed for day care use, and the Garage is not allowed for day care use. The backyard is fenced and used for outdoor activity. There were no bodies of water observed. Licensee stated that there were no weapons stored on the premises. A fully charged fire extinguisher was observed. Carbon monoxide and Smoke Detectors were tested and proved to be functioning. Fire/Disaster Drill log recorded that the last drill was conducted on 08/16/19. Licensee stated that the day care does provide transportation to the children. LPA reviewed and obtained a copy of the roster of children in care. Children’s files were reviewed, which included records of Identification and Emergency Information, Consent for Emergency Medical Treatment, Receipt for Parents' Rights Notice, and Immunization.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2019
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 5
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: MOHAMMED, FETHYA
FACILITY NUMBER: 434414604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2019
Section Cited

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PARENTAL AND AUTHORIZED REPRESENTATIVE'S RIGHTS. The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent [...] has received and read the LIC 995A.
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This requirement is not met as evidenced by:
Per LPA's review of files, Licensee failed to obtain the signature the signature of Child 4, 5, and 6's parent on the form LIC995A. Also, Licensee was unable to locate Child 7's file during the inspection. This poses a potential risk to the health and safety of children in care.
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Type B
10/14/2019
Section Cited

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APPLICATION FOR LICENSE. Licensees and any adult in the home, shall provide evidence of a current tuberculosis clearance, performed and signed by a physician not more than one year prior to or seven days after first day of employment.
This requirement is not met as evidenced by:
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Per LPA's review of records, Licensee failed to provide evidence of a current Tuberculosis Clearance for Assistant Provider Najat Erragi. This poses a potential risk to the health and safety of 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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: MOHAMMED, FETHYA
FACILITY NUMBER: 434414604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2019
Section Cited

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OPERATION OF A FAMILY CHILD CARE HOME. An emergency information card shall be maintained for each child and shall include [...] the parent's authorization for the licensee or registrant to consent to emergency medical care.
This requirement is not met as evidenced by:
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Per LPA's review of files, Licensee failed to obtain authorization from Child 1 and 2's parent for Licensee to consent to emegency medical care for Child 1 and 2. This poses a potential risk to the health and safety of children in care.
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Type B
10/07/2019
Section Cited

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IMMUNIZATIONS. The licensee shall document each child's immunizations [...] and maintain such documentation for as long as the child is enrolled. This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.
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This requirement is not met as evidenced by:
Per LPA's review of files, Licensee failed to update Child 3, 4, and 5's immunization record. Also, LPA did not observe any immunization record for Child 6 in the file and Licensee was unable to find Child 7's file. This poses a potential risk to the health & safety of children.
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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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: MOHAMMED, FETHYA
FACILITY NUMBER: 434414604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2019
Section Cited

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HEALTH & SAFETY CODE. Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against [...], pertussis, and measles. [...] The family day care home shall maintain documentation of the required immunizations.
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This requirement is not met as evidenced by:
Per LPA's review of files, Licensee failed to maintain documented proof of Assistant Provider Najat Erragi's immunization against Measles and Pertussis. This poses a potential risk to the health and safety of 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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: MOHAMMED, FETHYA
FACILITY NUMBER: 434414604
VISIT DATE: 09/30/2019
NARRATIVE
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Licensee and Assistant Provider/Volunteer Najat Erraji's files were reviewed, which included record for Criminal and Child Abuse Background Check Clearance, immunization, required Training etc. Licensee's AB1207 Mandated Reporter Training expires on 03/03/20 and her Pediatric CPR/1st Aid Certificate expires on 04/2021.

Adults who reside in the home are Licensee, and Licensee's Spouse. They have Clearances for Tuberculosis, and Criminal Background and Child Abuse Index Checks. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

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.
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 reviewed and provided a copy of the “Lead Poisoning Facts Information Flyer” and Safe Sleep information to Licensee.

Incidental Medical Services (IMS) policy was discussed. Licensee stated that she currently does not have any children in care who requires IMS. 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) & link to Commonly Asked Questions and the ADA, available at:<http://www.ada.gov/childqanda.htm> .

In the areas that were evaluated, regulatory violations were observed at the time of the inspection.
Exit interview was conducted, where this report, the violations, plan of corrections, and appeal rights were reviewed with Licensee.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5