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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700150
Report Date: 07/19/2021
Date Signed: 07/19/2021 12:13:06 PM

Document Has Been Signed on 07/19/2021 12:13 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:SHAHID, FOUZIAFACILITY NUMBER:
015700150
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
07/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Fouzia ShahidTIME COMPLETED:
12:15 PM
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(1) Licensing Program Analyst (LPA) Melanie Otsuji arrived to the facility unannounced on today's date, 7/19/2021, to conduct a Required - 1 Year inspection. LPA was met by Licensee Fouzia Shahid. Present during today's visit was the Licensee's two school-age children, fingerprint cleared spouse and 3 children (1 infant and 2 preschoolers). LPA conducted a health and safety inspection inside and outside.

ON LIMIT AREAS: Day care room/Living Room, bathroom, fenced front yard and backyard.
OFF LIMIT AREAS: All bedrooms, kitchen and the garage. The off-limit area will be inaccessible by closed and/or locked doors and a child safety gate for the kitchen area.

There are no pools, spas, or similar bodies of water on the premises. Per Licensee, there are no firearms or other dangerous weapons on site. Storage areas for poisons are inaccessible. Detergents and other cleaning compounds that can pose a danger to children are stored where inaccessible. A fully charged 3A40BC fire extinguisher, carbon and monoxide detectors were observed to be operable. The home is kept clean, and orderly with ventilation for safety and comfort. LPA observed safe toys, play equipment and materials. The home has a working telephone on site. Outdoor play areas are fenced and supervision is provided while children are outside. On today's date, Licensee was within the proper capacity for their small family child care home license. Licensee stated if a child in care falls ill, the patio couch will serve as an isolation area until parents are able to pick their child up. All individuals present during today's date had the proper criminal record clearance. Each child's filed contained the appropriate emergency information card. Licensee has current Preventative Health Training and Pediatric CPR/First aid which expires on 8/9/2022.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAHID, FOUZIA
FACILITY NUMBER: 015700150
VISIT DATE: 07/19/2021
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Licensee was reminded that anyone working, residing or frequently visiting the home must be fingerprint cleared prior to being in the presence of children, or an immediate civil penalty can be assessed. Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.

Individual Medical Services (IMS) policy was discussed. This facility provides IMS to children in care. When any changes to the IMS plan is made, an updated 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: http://www.ada.gov/childqanda.htm

No deficiencies are being cited during today's visit. An exit interview was conducted. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. This report must be available for public review for 3 years. LPA provided Notice of Site visit and Licensee posted visit notice in LPAs presence. Notice of Site Visit must remain posted for the next 30 days.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC809 (FAS) - (06/04)
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