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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414604
Report Date: 07/15/2021
Date Signed: 07/15/2021 04:14:29 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: 4DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Fethya MohammedTIME COMPLETED:
04:15 PM
NARRATIVE
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LPA Anna Morales conducted an unannounced Annual/Required Inspection ( Tool Kit One) LPA met with Licensee, Fethya and her husband. Licensee stated that her husband assists her when needed which includes being left alone at times. Licensee stated that she has eight children (active),however at today's visit, LPA observed four children(one is 14 months, one is two years old, one is four years old and one is nine years old).She stated that there are no children under twelve months old. Last disaster drill was conducted on 7/6/2021.

Days and hours of operation are Monday through Saturday from 06:00 AM to 06:00 PM.- Adults over the age of 18 and residing in the home are the Licensee and her spouse. All adults have Criminal Background Check Clearances, signed Criminal Record Statements LIC508 on file with Licensing Office.

LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters inside the home 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. There were no baby walkers at the day care.

LPA observed a fully charged 2A10 fire extinguisher and working smoke/carbon monoxide detectors. (page 1)
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
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
VISIT DATE: 07/15/2021
NARRATIVE
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LPA reviewed a random selection of Emergency Information Cards(LIC700) which were complete and updated. 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 comes in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.

Incidental Medical Services (IMS) policy was discussed. The Licensee stated that she does not have take care of children who are ill. 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. Licensee has an area where sick children can be isolated from the others.
Licensee and husband don't have current Mandated Reporter Certificate. The last Mandated Reporter Certificate expires for Licensee is 3/2020. LPA was unable to observe a Mandated Reporter Certificate for Licensee's Husband. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed atwww.mandatedreporterca.com.

Husband has current CPR and First Aid card. It expires in 4/2023. Licensee's expired 4/2021

Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates
LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov (page 2)
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
LIC809 (FAS) - (06/04)
Page: 2 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: 07/15/2021
NARRATIVE
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Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time with a qualified assistant present. LPA reminded the Licensee that she must comply with the ratio/capacity requirements at all times. The Licensee states that she does not transport children.

LPA discussed and left a copy of Pin 20-24-CCP, RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT. Discussed that all INFANTS UP TO 12 MONTHS OF AGE MUST HAVE AN INDIVIDUAL INFANT SLEEPING PLAN (LIC9227) OF FILE, WHICH WILL DOCUMENT THE INFANTS SLEEPING HABITS, USUAL SLEEPING ENVIRONMENT, AND THE INFANT ROLLING ABILITIES.

Deficiencies are being cited based on the LPA's observations, interviews conducted and records reviewed in accordance with the California Code of Regulations Title 22.

A NOTICE OF SITE VISIT WAS ISSUED, AND TO BE POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
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: 07/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2021
Section Cited

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MANDATED REPORTER TRAINING. [...] a person who, on January 1, 2018, is a licensed child care provider [...] shall complete the mandated reporter training provided [...] and shall complete renewal mandated reporter training every two years
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LPA observed that Licensee did have not current Mandated Reporter Training.It expired on 3/2020 and her husband Khamal Mohanned does not have training on file. This poses a potential risk to children's health and safety of children in care.
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Type B
08/12/2021
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:
LPA was unable to review immunizations record for C1 This poses a potential risk to the health & safety of children.t
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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: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2021
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: 07/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2021
Section Cited

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Personnel Requirements. The licensee and other personnel as specified, shall complete training on preventive health practices including CPR and first Aid.
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Licensee CPR/1st Aid certificate expired in 4/2021.
This poses a potential risk to the Health, Safety, or Personal Rights 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: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5