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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415491
Report Date: 05/19/2022
Date Signed: 05/20/2022 04:15:28 PM


Document Has Been Signed on 05/20/2022 04:15 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:MOHAMMED, AZIZAFACILITY NUMBER:
434415491
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
05/19/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Aziza MohammedTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management- Licensee Initiated inspection. LPA met with Licensee Aziza Mohammed and explained the reason for the inspection. The purpose of this inspection is Licensee is requesting for a change of capacity to a large Family Child Care Home (FCCH). Licensee has been licensed since 10/26/2018; thus has at least one year of experience to apply for a large FCCH. A fire clearance for 14 children was granted on 05/09/2022. Present during today's inspection were Licensee, her spouse, her adult son, her minor daughter, and 6 children, whom 2 are infant age. The last annual inspection was conducted on 10/21/2021.

LPA toured the inside and outside of the home. The off-limit areas of the home are bedroom #1, bedroom #2, bedroom #3, the bathroom between bedroom #2 and bedroom #3, and garage. Licensee stated that school-age children will go through the kitchen to get to the dining area and/or kids room. LPA did not observe any children in the kitchen area and Licensee has a gate that blocks the kid room to the kitchen. LPA inspected the kitchen and observed that there were knives in the cabinet. Licensee moved knives to cabinet that is inaccessible to children. All other disinfectant, cleaning supplies, and other items that are dangerous to children were inaccessible to children. There is a fireplace in the home, which does not have a barricaded. LPA observed that there is a table there with decorations. There were no baby walkers observed during today's inspection. LPA observed at 2:28PM that one of the infants was in the car seat drinking a bottle. LPA discussed with Licensee that car seats should not be used other than for transporting infants. Licensee removed infant from the car seat. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Licensee stated that there are no weapons, such as firearms, stored in the home.

The backyard is used and is fenced. The off-limit areas outside are the left side of the home and the sandbox area. There were no bodies of water observed during today's inspection.
---------------------------continues on 809 dated 05/19/2022 page 2--------------------------------
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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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: 05/19/2022
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----------------------continuation of 809 dated 05/19/2022 page 1-----------------------------------

LPA observed that there were bumpers and blankets inside of the crib. LPA also observed that there was a blanket that was laid on bottom of the playyard and pillows. Licensee removed bumper from the crib and the blankets from the crib and playyard during today's inspection. There were no infants sleeping at the time of today's inspection. LPA provided Licensee with PIN 20-24-CCP during today's inspection. Licensee stated that she only uses the playyard for the infant to sleep. 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 for 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.

The adults 18 and over living in the home are Licensee, her spouse, and her two adult children. All adults have cleared criminal record, child abuse, and TB test. 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.

A updated LIC 279B, updated 999A, brief statement financial, and LIC 9515 were obtained during today's inspection. Licensee stated that she submit the following:
- updated lease agreement

As a result of this inspection, one type B and two technical violations were issued. Exit interview conducted and report was reviewed with the licensee Aziza Mohammed. Licensee was informed that upon receipt of Licensing Management's approval, a license for a Large Family Child Care Home will be granted and issued to Licensee. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/20/2022 04:15 PM - It Cannot Be Edited

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: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2022
Section Cited

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Car seats shall only be used for transportation purposes...

This requirement was not met as evident by:
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Based on observation, LPA observed at 2:28PM that an infant was drinking a bottle in the car seat, which poses a potential risk to the health and safety to the children in care.
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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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
LIC809 (FAS) - (06/04)
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