434415491-10-21-2021-07-CC-ASHA-C823ZQ-20211021184155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415491
Report Date: 10/21/2021
Date Signed: 10/21/2021 06:42:20 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, AZIZA		FACILITY NUMBER:	434415491
ADMINISTRATOR:	MOHAMMED, AZIZA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 970-9860
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95050
CAPACITY:	14	CENSUS: 12	DATE:	10/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Mohammed Aziza		TIME COMPLETED:	06:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA's) Aman Sharma and Samantha Yip arrived at licensee Mohammed Aziza's residence at 1:25pm and conducted an unannounced Required 1-Year inspection. LPA met with Licensee Aziza Mohammed and explained the reason for the inspection. Upon arrival, present during today's inspection were Licensee, her spouse, her minor child, 10 children, whom 2 were infant age. Upon entering, LPA's first went through children's files. LPAs reviewed 11 children's files. The records reviewed included but not limited to emergency contact card, LIC 627: Consent for Emergency Medical Treatment, and LIC 282. LPA observed that all children did not have consent for emergency medical treatment and LIC 282 on file. Licensee stated that she will have parents fill out the LIC 627 and LIC 282 and send a copy to Licensing by 10/29/2021. LPA also reminded Licensee to check that all forms are filled out and signed. LPAs inspected the inside and outside of the home with Licensee. The off-limit areas of the home are all three bedroom, dining room, living room, and kitchen. LPAs observed upon arrival that there was one child in the dining room. LPA informed Licensee that she needs to inform Licensing if she wants to make any off-limit areas for the children's use. LPA inspected the dining room and kitchen. LPA observed that there were knives in the bottom drawer and cleaning supplies, such as disinfectant sprays, that are accessible to children. Licensee moved the knives and cleaning supplies to a higher shelf, which is inaccessible to children. The dining room and kitchen was observed to be safe for children. Licensee will submit updated LIC 999 to reflect the changes to the on-limit areas to Licensing by ---------------------CONTINUES ON 809 DATED 10/21/2021 PAGE 2---------------------------

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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, AZIZA	FACILITY NUMBER: 434415491
	VISIT DATE: 10/21/2021

NARRATIVE

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-------------------CONTINUATION OF 809 DATED 10/21/2021 PAGE 1--------------------------

10/29/2021. There is a fireplace in the family room/kid area, which was barricaded and one in the living room, which was not. LPAs observed that there is sufficient amount of toys for children in care. There were no baby walkers observed during today's inspection. There is fully charged fire extinguisher and a functioning combination smoke and carbon monoxide detector. The last fire drill was conducted on 08/2021. LPA reminded Licensee to document all fire drills. Licensee stated that there are no weapons, such as firearms, stored in the home.

Licensee does use the backyard, which is fenced. LPAs observed that sandbox area has wood that is starting splinter and nails that were starting to rust and starting to come up. Licensee stated that she is currently working with her landlord to have area fixed. She stated that she will make the sandbox are off-limits temporarily until it is fixed. LPAs reminded Licensee to check plastic play equipment and toys for any cracks. There were no bodies of water observed during today's inspection.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee's spouse transport children and does have a valid driver's license. Licensee's spouse however does not have a valid CPR/1st Aid. LPAs explained to Licensee that her spouse needs to have a valid CPR/1st Aid. She stated that she will have her husband complete the CPR/1st Aid and send proof to Licensing.

------------------------CONTINUES ON 809 DATED 10/21/2021 PAGE 3----------------------------

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

Page: 2 of 12

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
	VISIT DATE: 10/21/2021

NARRATIVE

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-----------------------CONTINUATION OF 809 DATED 10/21/2021 PAGE 2-----------------------

Licensee stated that she does not provided Incidental Medical Services. IMS policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, an Plan of Providing IMS must be submitted to Licensing. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514- 0301 (voice)/ (800) 514-0383 (TTY) and link to publications: Commonly Asked Questions about Child Care Center and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPAs also reviewed Licensee and her spouse's file. Licensee could not show proof of a valid CPR/1st Aid. She stated that she completed the CPR/1st Aid with American Red Cross and will contact them to obtain a copy of her card. Licensee completed the Mandated Reporter training on 09/06/2021. Licensee stated that her husband has not completed the Mandated Reporter training, but will have him complete it and send proof to Licensing. Licensee's spouse also was not able to show proof of immunization records for pertussis and measles. Licensee stated that she will obtain a copy of immunization records and send proof to Licensing.

The adults living in the home are Licensee, her spouse, and her two adult children. Licensee also has one minor child. All adults have cleared criminal record, child abuse index, and TB clearance. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

------------------------CONTINUES ON 809 DATED 10/21/2021 PAGE 4---------------------

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

Page: 3 of 12

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
	VISIT DATE: 10/21/2021

NARRATIVE

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--------------------CONTINUATION OF 809 DATED 10/21/2021 PAGE 3--------------------------

As a result of today's inspection, 1 Type A, 4 Type B, 3 Technical Violation, and 2 Technical Assistances were cited. Exit interview conducted and report, citation, plan of correction, and appeal rights were discussed and provided to Licensee Aziza Mohammed.

LPA also discussed about AB 633 requirement to provided a copy of 809 report dated 10/21/2021 and obtain a signed copy LIC 9224 for each child in care within one business day. LPA also discussed with Licensee Aziza Mohammed that a copy of this report and a signed copy of LIC 9224 is required for any newly enrolled children within the 12 month period. LPA will email a copy of LIC 9224 and fact sheet to Aziza Mohammed.

A Notice of Site Visit was given and must be posted for 30 days; along with a copy of the report.

LPA discussed with Licensee about Technical Support Program. Licensee stated that she would want to be referred.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

Page: 4 of 12

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: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416.3(a)(6)

Alterations to Existing Building or Grounds

(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Licensee did not inform Licensing to change the dining room and kitchen to an area for children, which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2021
	Plan of Correction
1 2 3 4	Deficiency was corrected during today's inspection. LPA inspected the dining room and kitchen and observed that it was safe for the children. Licensee stated that she will submit an udpated LIC 999 to reflect the changes to on-limit areas.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

Page: 5 of 12

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: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(4)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed that there was a knife on the counter and drawers, along with cleaning supplies that were accessible to children. This posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2021
	Plan of Correction
1 2 3 4	Deficiency was corrected during today's inspection. Licensee moved knives and cleaning supplies to an area that was inaccessible to children.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviews, the licensee did not comply with the section cited above. Licensee's spouse was helping with the daycare and did not complete the Mandated Reporter training. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2021
	Plan of Correction
1 2 3 4	By POC 12/06/2021, Licensee stated that she will have her spouse complete the Mandated Reporter training and send proof to Licensing.

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 Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

Page: 6 of 12

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: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Licensee and her spouse did not have a valid CPR/1st Aid card, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2021
	Plan of Correction
1 2 3 4	By POC 11/22/2021, Licensee stated that she and her spouse will complete the CPR/1st Aid and send proof to Licensing.

Type B

Section Cited

CCR

102417(m)(3)

Operation of A Family Child Care Home

(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviews, the licensee did not comply with the section cited above. LPAs observed that all children did not have affidavit signed and in their file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2021
	Plan of Correction
1 2 3 4	By POC 10/28/2021, Licensee stated that she will have parents fill and sign the affidavit and send proof to Licensing.

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 Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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