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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423850
Report Date: 07/05/2023
Date Signed: 07/05/2023 05:14:59 PM

Document Has Been Signed on 07/05/2023 05:14 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:COOPER, DAEJENAEFACILITY NUMBER:
013423850
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
07/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:Daejenae CooperTIME COMPLETED:
05:20 PM
NARRATIVE
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On 7/5/23 at 3:38pm, Licensing Analyst (LPA) Catherine Fernandes arrived to the home on a case management inspection and met with Licensee Daejenae Cooper. Present in care was two infants, four preschoolers and two school age children.

Upon arrival LPA observed Amina Ayesh with the children at the park across from the home and staff #2 was walking back to the house. When asked for fingerprints for Ayesh, Licensee stated she got fingerprinted but was not associated to the facility. During the visit no proof of fingerprints or clearance was provided during the case management inspection. Licensee stated Ayesh started on 7/3/23.

LPA Fernandes informed Licensee Cooper that this report dated 07/05/23 documents a Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the safety of the children in care.
Also, LPA Fernandes informed Licensee Cooper to provide a copy of this licensing report dated 7/5/23 that documents a Type A citation 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.

See 809D for deficiency cited

Notice of site visit provided and must be posted for 30 days.

Exit interview conducted with Cooper

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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 07/05/2023 05:14 PM - It Cannot Be Edited


Created By: Catherine Fernandes On 07/05/2023 at 03:38 PM
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: COOPER, DAEJENAE
FACILITY NUMBER: 013423850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2023
Section Cited
CCR
102370(d)

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Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 prior to working, residing, or volunteering in a licensed facility. This requirement has not been met as evidenced by
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Licensee will immediately remove the Amina Ayesh for home.

A $300 Civil penalty has been assessed.

During the visit Licensee sent Ayesh home.
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Based on guardian no clearance or fingerprints were in the system for Amina Ayesh which is an immediate safety risk to 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:Mayla Mendoza
LICENSING EVALUATOR NAME:Catherine Fernandes
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
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