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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415491
Report Date: 08/06/2019
Date Signed: 08/06/2019 12:39:06 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, AZIZAFACILITY NUMBER:
434415491
ADMINISTRATOR:MOHAMMED, AZIZAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 970-9860
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:14CENSUS: 5DATE:
08/06/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Aziza MohammedTIME COMPLETED:
12:45 PM
NARRATIVE
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At 12:00 PM on 08/06/19 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Case Management - Other inspection at Aziza Mohammed's family day care. Present in the home were Licensee and five infants in care.

Licensee is in violation of California Code of Regulations Title 22 under 102416.5(d) Staffing Ratio & Capacity that states: The maximum number of children for whom care may be provided at any one time shall be either: (1) 12 children, no more than 4 of whom may be infants; or (2) More than 12 and up to 14 children only if no more than 3 are infants, and at least 1 child is enrolled in school, and 1 child is at least 6 years old.

Licensee is out of ratio by one infant. Licensee states she accepted an extra infant because another infant is turning 2 years old next week, she took a chance and she was fully aware she should not have done so.

Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care. Report also has to be provided to the parent of children who are enrolled over the next 12 months. In addition, a copy of the Acknowledgement of Receipt of Licensing Reports LIC 9224 must be signed by each parent and kept in each child's file. LPA provided Fact Sheet AB633 to Licensee.
LPA reminded Licensee that failure to correct deficiencies by Plan of Correction Due Date may result in penalties of $100 per day per violation.

A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED NEAR THE FRONT ENTRANCE TO THE HOME FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2019
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, AZIZA
FACILITY NUMBER: 434415491
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2019
Section Cited
CCR
102416.5(d)
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STAFFING RATIO AND CAPACITY.
The maximum number of children for whom care may be provided at any one time shall be either: (1) 12 children, no more than 4 of whom may be infants; or (2) More than 12 and up to 14 children only if no more than 3 are infants, and at least 1 child is enrolled in school, and 1 child is at least 6 years old. This requirement is not met as evidenced by:
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By POC Due Date Licensee agreed to submit: A written statement explaining her understanding of this regulation Licensee will also submit a day and time schedule of children in care that ensures there are no more than 4 infants in care.
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Per LPA's inspection and file review, there were 5 infants present during the inspection. Licensee is out of ratio by 1 infant. This is an immediate risk to the health and safety of children in care.
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Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care. Report also has to be provided to the parent of children who are enrolled over the next 12 months. In addition, a copy of the Acknowledgement of Receipt of Licensing Reports LIC 9224 must be signed by each parent and kept in each child's file. LPA provided Fact Sheet AB633 to Licensee.
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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: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2