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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009700
Report Date: 11/17/2022
Date Signed: 12/14/2022 09:19:35 AM


Document Has Been Signed on 12/14/2022 09:19 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/13/2022 10:22 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

NARRATIVE
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An case management inspection was made to the facility by Licensing Program Analyst (LPA), C. Fernandes-Goes. LPA arrived announced to conduct an annual required visit. Licensee Nahid Mujadid wasn't present at the facility due to a family emergency. LPA observed 13 children in care with 3 staff. Licensee spoke with LPA on the phone. According with a review of Guardian Staff Roster, Department learned that 2 out of 3 staff are not fingerprint cleared and/or associated to the facility. Licensee confirmed that staff S1 started working at facility on and off 2 months ago and S2 started working around a 1 month ago. Staff records on 11/17/2022 indicates that 2 facility staff or other individuals who require caregiver background checks have not received criminal record and child abuse index clearances or exemptions. 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. Licensee understands that children can not be left under the supervision of staff that don't meet requirements. Licensee stated that parents were going to be called to pick up children. At this time facility will only keep the number of children allowed under the supervision of 1 staff S3 who is fingerprint cleared and associated to the facility. Annual Required visit will be conducted at another time.

Licensee to provide Department w/ self-certification that all adults over 18 years of age in the facility premises have been fingerprint cleared and associated to the facility by 11/18/22.


Fingerprint/ No Association: Civil penalties are assessed at the rate of $100 per day per employee staff S1 & S2 for the period of 5 days in accordance with Title 22 Regulations # 102370(d) *****Total Civil Penalties issued today in the amount of $1,000.00.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the staff, Makai Esmati. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

SUPERVISOR'S NAME: Jordan MonathTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Alexis HollonTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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Document Has Been Signed on 12/16/2022 08:59 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/13/2022 10:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: MUJADIDI, NAHID FCCH
FACILITY NUMBER: 483009700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/18/2022
Section Cited

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(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:This requirement is not met as evidenced by:
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LPA reminded Licensee that all adult 18 years & older residing in the home or working is required to obtained an approved criminal record clearance. Licensee stated she would contact parents to have
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Based on the Licensee's statement, Obs., & Guardian review 2 of 3 staff are not fingerprint cleared or associated to facility. The licensee did not comply w/ section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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them pick up some of the children so 1 staff would be in ratio and S1 & S2 would be asked to get fingerprinted & not return to facility premises until cleared and associated. Licensee to provide Department w/ self-certification that all adults over 18 years of age in the facility premises have been fingerprint cleared and associated to the facility by 11/18/22.

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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: Jordan MonathTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Alexis HollonTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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