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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414604
Report Date: 09/20/2021
Date Signed: 09/21/2021 09:30:46 AM

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:
09/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Fethya MohammedTIME COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Morales conducted a CASE MANAGEMENT visit and was greeted by Licensee Fethya Mohammed. Also, present was Khamal Mohammed (Licensee's husband) and staff Sebrir Hussen. There were eight children present ( three under the age of two years of age) and five preschool aged children.

LPA learned that employee Sebrir Hussen was not associated to the facility. According to the Licensee, Sebrir began employment on 9/1/21. LPA reviewed supporting documentation dated on 6/16/2019, that Licensee Fethya Mohammed signed to dissociate Sebrir Hussen from the facility. On 6/17/2019, Sebrir Hussen was dissociated from the facility. LPA showed the supporting documentation to the Licensee and she confirms that she dissociated her from the facility in error, however, did not re-associate Sebrir Hussen prior to her employment(9/1/21).

California Code of Regulations, (Title 22, Division 12 & Chapter 1), is being cited on the attached LIC 809D. Copy of appeal rights provided to the Licensee

A notice of site visit was issued and is to be posted near the facility entrance along with the Type "A" deficiency issued today and both notices must remain posted for 30 consecutive days. The Licensee must provide copies of this report to parents/guardians of children in care at this facility and Acknowledgement of Receipt of Licensing Reports (LIC9224) to parents/guardians of children newly enrolled at this facility during the next 12 months, and parents to return this form with signature to the facility.





SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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: MOHAMMED, FETHYA
FACILITY NUMBER: 434414604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2021
Section Cited

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j)
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This requirement was not met as evidenced by: Based on observation, Licensee dissociated Staff Sebrir Hussen on 6/16/2019, and according the Licensing Information System (LIS)Sebrir Hussen was disassociated on 6/17/19. Licensee confirms the dissociation. Sebrir Hussen began employment on 9/1/2021, which poses an immediate risk to the Health, Safety or Personal Rights to the children in care
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AB633 Parent Notification is required. This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.

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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: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021
LIC809 (FAS) - (06/04)
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