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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415080
Report Date: 03/04/2022
Date Signed: 03/04/2022 03:04:13 PM


Document Has Been Signed on 03/04/2022 03:04 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:SELIMOVIC, BELMAFACILITY NUMBER:
434415080
ADMINISTRATOR:SELIMOVIC, BELMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 603-8911
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:14CENSUS: DATE:
03/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Belma SelimovicTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Aman Sharma and Mel Matos met with Licensee Belma Selimovic, for an unannounced case management investigation. Purpose of today's investigation: discuss an unusual incident that the Licensee self reported to the San Jose Child Care District Office. LPAs also observed eight day care children in the home (two infants and six preschool), two adult assistants, and Licensee's spouse during today's inspection. LPAs interviewed the Licensee and one day care child's mother (via phone) for this investigation.

Licensee reported that an infant child had an allergic reaction to liquid infant formula on Monday February 28, 2022. Licensee states that Monday was the first time that the child had been given liquid infant formula at the day care since the child started attending the day care on January 23, 2022. Licensee states that the child was drinking breast milk provided by the child's mother prior to Monday February 28, 2022. Licensee states that the child's mother brought her the liquid infant formula on Monday February 28, 2022. Licensee states that she is not aware that the child had any allergies to any type of formula prior to Monday February 28, 2022.

Licensee states that she did have to call the child's parents when she noticed that the child's lips, eyes, and cheeks were swollen after drinking the first bottle of liquid infant formula on Monday February 28, 2022. Licensee states that the child was not under any distress. Licensee states that the child's mother came to pick up the child from the day care and the child was taken to Kaiser Hospital for observation. Licensee states that the child was not admitted to the hospital and doctors determined that the child had an "allergic reaction" to the liquid infant formula. Licensee states that the child's mother has changed the type of formula given to the child and states that the child is doing fine now. Licensee states that the child returned to the day care on Tuesday March 1, 2022 without any restrictions.
LPAs conducted an exit interview with the Licensee and advised her that no deficiencies issued as a result of the Unusual Incident.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Aman SharmaTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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