<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423485
Report Date: 04/08/2022
Date Signed: 04/08/2022 11:38:13 AM

Document Has Been Signed on 04/08/2022 11:38 AM - 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:IRFAN, ASMAFACILITY NUMBER:
013423485
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 4CENSUS: 2DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Asma IrfanTIME COMPLETED:
11:45 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
On 04/08/2022 approximately at 8:40AM Licensing Program Analyst (LPA) Kelly Phan arrived at for an unannounced required inspection, and met with Licensee Asma Irfan. There were 2 preschool aged children present. Also residing in the home is the licensee's fingerprinted and associated husband and their three daughters (11, 15, and 18). The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 7:00am to 6:00pm.

ON LIMITS: hallway bathroom, full backyard, living room (used as isolation area), family room, kitchen, and bedroom (master bedroom)
OFF LIMITS: garage, two side yards, bathroom #2 (in master bedroom), bedroom #2, bedroom #3, bedroom #4, bathroom #3, and bathroom #4, and front yard. Off limit areas are inaccessible by closed and/or locked doors, gates, and full visual supervision.

The home is single story, which is neat and clean, with heating and ventilation for safety and comfort. There were ample age appropriate toys that were observed to be safe and in good condition. Toxins, medicines, and hazardous items were inaccessible during today's inspection. There were a fully charged 2A10BC fire extinguisher and a dual working carbon monoxide and smoke detector, along with a working telephone. The home has a fireplace but is blocked off. Per licensee, there are no firearms or pets or any bodies of water in the home. The licensee conducts and documents fire drill log indicates a drill was conducted 03/03/2020. Per licensee, she was not conducting drills as she was closed and was reopen in September 2021 due to COVID pandemic. All required licensing documents are posted and visible for public review. At 8:50AM, LPA asked licensee who resides in her home; licensee states that she has three daughters between ages of 11, 15, and 18 years old along with her husband. LPA verified with Guardian association list that her daughter was not listed and interviewed with licensee that she was not aware to associate her as she is going back and forth to college. LPA informs licensee that a Type A violation and civil penalty of $500.00 as licensee states her daughter has been residing at her home, which would be issued for violation of background clearance.
SEE LIC 809 C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: IRFAN, ASMA
FACILITY NUMBER: 013423485
VISIT DATE: 04/08/2022
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
26
27
28
29
30
31
32
At 9:00AM, LPA and licensee toured the outdoor area and found it to be safe and in good condition as all play equipment did not have any defects. Both side yards are fenced to prevent any access to children in care. At 9:30am, 4 children's files were reviewed and 1 child's immunization was missing; However licensee was able to obtain it from child's mother via text message today. LPA informs licensee to print out immunization record and keep it in the child's file for 3 years. The facility roster was reviewed, and a copy obtained. Licensee has proof of the required immunization; There is a declaration of declining the flu shot. The licensee have required mandated reporter training that is completed as of 06/22/2021. CPR and First Aid training are also updated as of 06/12/2023.

At 10:00AM, LPA and licensee toured the sleeping bedroom for children in care, and found it to be safe. There were no objects or loose articles inside or attached to the cribs. LPA also suggests to licensee to have a sleep log and to have the door open if she is in a separate room from the sleeping children or use a baby monitor device but shall not be used in place of sleep log requirements; licensee would send proof of sleep logs to LPA by 4/11/2022. Staff interview conducted and documented.

There were one deficiencies were cited for today's inspection:

Type A: After LPA verified and spoke with licensee, she failed to obtain background clearance for her adult daughter who turned 18 years old. See LIC 809D along with a civil penalty of $500.00.

Appeal rights and 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 $100.00. Exit interview conducted and report was reviewed with licensee Asma Irfan
SEE LIC 809 C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: IRFAN, ASMA
FACILITY NUMBER: 013423485
VISIT DATE: 04/08/2022
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
26
27
28
29
30
31
32
LPA Kelly PHAN informed licensee Irfan that this report dated 04/08/2022 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Kelly PHAN informed the licensee to provide a copy of this licensing report dated 04/08/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.


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.

Incidental Medical Services (IMS) policy was discussed. This facility does not provides IMS to children in care. 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 publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.”


SEE LIC 809 C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/08/2022 11:38 AM - It Cannot Be Edited


Created By: Kelly Phan On 04/08/2022 at 10:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: IRFAN, ASMA
FACILITY NUMBER: 013423485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation,interview, and record review, the licensee did not comply with the section cited above as licensee failed to obtain a criminal clearance for her adult daughter who has resides at her facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
1
2
3
4
Licensee would ask her adult daughter to obtain a livescan and send proof of corrections to LPA by 4/11/2022
LIcensee would call approved UPS stores to verify if they do LIVEscan services and make an appontment if necessary
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:Jason Jang
LICENSING EVALUATOR NAME:Kelly Phan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: IRFAN, ASMA
FACILITY NUMBER: 013423485
VISIT DATE: 04/08/2022
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
26
27
28
29
30
31
32
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 was reminded that California Law requires licensed Child Care Centers to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5