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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415491
Report Date: 08/12/2019
Date Signed: 08/12/2019 02:21:21 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: 4DATE:
08/12/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Aziza MohammedTIME COMPLETED:
02:30 PM
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On 08/12/19 Licensing Program Analyst (LPA) Monica Mathhur and Licensing Program Manager (LPM) Sandy Knight conducted an unannounced Plan of Correction (POC) inspection at Aziza Mohammed's family day care. Present in the home were 4 infants and Licensee, Aziza and her teenage daughter. LPA explained the reason for the inspection.

On 08/06/19 during a Case Management inspection, facility was cited for Type A violation under CCR 102416.5(d) Staffing Ratio & Capacity. Licensee submitted plan of correction by POC due date and facility is in compliance during todays inspection. Review of children files shows each contained LIC9224 Statement Acknowledgement of Licensing Report signed by each child's authorized representative. Letter of clearance for the mentioned citation was issued during the visit.

No deficiencies were issued today.

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: 08/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2019
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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