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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423878
Report Date: 06/26/2024
Date Signed: 06/26/2024 12:24:25 PM

Document Has Been Signed on 06/26/2024 12:24 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SHUAIBE, HANEEFAHFACILITY NUMBER:
013423878
ADMINISTRATOR/
DIRECTOR:		HANEEFAH SHUAIBEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 381-4242
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
06/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Karima KouloughTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 06/26/2024 at 9:00 AM Licensing Program Analyst (LPA), A. Curry arrived at the home and conducted an unannounced annual/ random inspection. LPA met with licensee's fingerprint cleared assistant,Karima Koulough, who granted inspection authority to tour the facility. Also present for the inspection were licensee’s other fingerprint cleared assistant and 6 children in care, consisting of 4 infants and 2 preschoolers. The licensee was not present during today's visit. Assistant states there are currently 8 children enrolled. Children and staff files were reviewed. Staff did not have required immunization records in file (See 809D).

The children will use the two downstairs bathrooms, combined living room and dining room, kitchen, nook, and backyard. The off-limits areas will be inaccessible by closed and/or locked doors and visual supervision. The isolation area is the nook. The LPA toured all areas used by children.



Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There is safe toys, play equipment, and materials observed for children. There were no stairs. The stairs that lead to the upper part of the home is made inaccessible by a closed door. There is a working telephone in the home. All poisons, cleaning solutions, medications, and other items that pose a danger to children are inaccessible during this visit. The licensee does understand that poison must be in a locked cabinet/drawer or placed out of reach of children. The home is equipped with a fully charged 2A10BC fire extinguisher, working smoke alarm, and working carbon monoxide detector. Assistant states there are no firearms on the premises. There are no pools, spas, hot tubs, fishponds or similar bodies of water. The staff present during today's visit did not have a valid EMSA certified pediatric CPR/First Aid certification (See 809D).

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SHUAIBE, HANEEFAH
FACILITY NUMBER: 013423878
VISIT DATE: 06/26/2024
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LPA observed and inspected sleeping equipment for infants. All equipment meets the US Consumer Product Safety Commission standards. LPA observed that cribs and/or play yards were free from loose articles and objects. There are no objects hanging above or attached to the side of the crib. Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Assistant was advised that infants shall not be swaddled while in care and all infants up to 12 months of age should be placed on their back for sleeping. LPA observed an infant (C1), who is under 12 months of age, sleeping on their stomach without Section C of the LIC 9227 form completed by the infant's authorized representative (See 809D). The assistant was advised that Section C of the LIC 9227 must indicate the infant rolls over onto their stomach. If Section C is not completed, staff must continuously return the infant to their back.

LPA discussed the safe sleep regulations with facility representative 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 facility representative 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. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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: https://www.ada.gov/resources/child-care-centers/.

Facility representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
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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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SHUAIBE, HANEEFAH
FACILITY NUMBER: 013423878
VISIT DATE: 06/26/2024
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Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview Karima Koulough confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted, appeal rights were given, and report was reviewed with Karima Koulough.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/26/2024 12:24 PM - It Cannot Be Edited


Created By: Ashley Curry On 06/26/2024 at 11:44 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SHUAIBE, HANEEFAH
FACILITY NUMBER: 013423878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(C)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Infants up to 12 month of age who are sleeping in a position other than on their back.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and record review, the licensee did not comply with the section cited above by not ensuring all infants up to 12 months of age are sleeping on their back, which poses/posed a potential health, safety or personal rights risk to persons in care. Section C of the LIC 9227 form was not completed and/or did not indicate the child rolls onto their stomach, so staff must continuously return infant to their back.
POC Due Date: 07/26/2024
Plan of Correction
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Please email copy of LIC 9227 form with Section C completed.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not ensuring all staff have required immunization records in file, which poses/posed a potential health, safety or personal rights risk to persons in care. Please see LIC 859 for documents that are missing in each staff's file.
POC Due Date: 07/26/2024
Plan of Correction
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By 07/26/2024 email LPA proof of immunity to Measles for Rosa and proof of immunity to Pertussis for Karima.
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:Monica Mathur
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 06/26/2024 12:24 PM - It Cannot Be Edited


Created By: Ashley Curry On 06/26/2024 at 11:44 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SHUAIBE, HANEEFAH
FACILITY NUMBER: 013423878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not ensuring at least one person caring for children at all times has a current EMSA pediatric CPR/First Aid certification, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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By 07/10/2024 email me a written plan to comply with section cited above. ex another staff has valid certification or licensee always present during day care hours
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Monica Mathur
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
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