566215915-1-15-2020-17-CC-FPEA-BKUQYC-20200115113457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 566215915
Report Date: 01/15/2020
Date Signed: 01/15/2020 11:35:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	FAROOK FCC AKA SAFIA'S HOME DAYCARE		FACILITY NUMBER:	566215915
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	01/15/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Fathima Farook		TIME COMPLETED:	11:50 AM

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 Analyst (LPA) Francisco Pedroza conducted an announced Pre-licensing inspection. LPA met with applicant Fathima Farook and advised her the purpose of the inspection. LPA and applicant together toured the facility inside and out. Applicant has a three bedroom single story home. The applicant will be using a family room, living room, back yard, and one restroom for the day-care. LPA did not observe any toxins/hazardous items accessible to children. A regulation 2A10BC fire extinguisher purchased on 12/19/19 was observed mounted in a storage closet. Applicant is reminded to service or purchase the fire extinguisher yearly. LPA observed the home has functioning smoke and carbon monoxide detectors. In the family room LPA observed a cardboard covered fireplace with a modified couch in front preventing children from having access. Applicant advised that the fireplace would not be used. There are age appropriate toys and day-care equipment in the home. The back yard is enclosed with a cement wall. There are two six foot wood fences on each side of the yard. One leads to an enclosed area where the facility air conditioner is located. The other fence leads to the side of the house that exits to the front of the facility. The back yard has age appropriate toys and day-care equipment. LPA observed sufficient shade for children to have access. LPA advised applicant must provide visual supervision while the children are playing outside in the backyard. Continued on 809-C

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2020

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: FAROOK FCC AKA SAFIA'S HOME DAYCARE	FACILITY NUMBER: 566215915
	VISIT DATE: 01/15/2020

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Applicant is enrolled to complete Preventative Health & Safety and Nutrition Training on 02/14/20. Applicant Pediatric First Aid/CPR certificates is valid until 03/13/21. Applicant AB 1207 Mandated Reporter Training Certificate expires 03/28/20. Applicant stated they do not have firearms and ammunition in the home. Currently the applicant does not have liability insurance. LPA informed applicant that she will need parents to sign a waiver for the liability insurance. Applicant provided lease agreement to verify control of property. LPA discussed and verify SB 792 (Child Care Employee and Volunteer: Immunization and Tuberculosis Requirements). Applicant was informed walkers, bouncers and any similar object that restricts children's movement is prohibited from licensed facilities.

LPA reviewed, discussed and gave applicant updated samples of state required forms to be kept in the children's file, required forms to be posted and forms that needs to be maintained at the Family Child Care Home (FCCH). LPA discussed information about Sudden Infant Death Syndrome, Never Shake a Baby, and Capacity requirements. A guide to Effects of lead poisoning and Safe Sleep pamphlet was provided to applicant. Applicant was made aware that it is her responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.cdss.ca.gov.

No deficiencies cited during this visit.

Provisional license will be effective today, January 15, 2020. Provisional license will expire in 90 days, if copy of Preventative Health is not submitted in 90 days.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2020

LIC809 (FAS) - (06/04)

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