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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700183
Report Date: 09/10/2021
Date Signed: 09/10/2021 04:55:20 PM

Document Has Been Signed on 09/10/2021 04:55 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:BAWAZIR, FATIMAFACILITY NUMBER:
015700183
ADMINISTRATOR:BAWAZIR, FATIMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 876-3616
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Fatima Bawazir and Abdul BawazirTIME COMPLETED:
04:40 PM
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On 9/10/2021 at 2:18pm Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Fatima Bawazir for an Unannounced Annual Inspection. Present during the inspection when LPA arrived was the Licensee, her fingerprint cleared husband Abdul Bawazir, three (3) school-age children, four (4) infants and one (1) preschooler. During the inspection the ratio went to three (3) school age children, one (1) infant and one (1) preschooler. Licensee lives in the home with her husband, fingerprint cleared daughter and cleared son-in-law. Licensee’s home was toured for a health and safety inspection. The facility is open for 24hours.

ON LIMITS AREA: Living Room, Dining Room, Kitchen, Family Room, Downstairs Bathroom, One (1) Upstairs Bedroom in the corner next to Master Bedroom and Portion of Backyard


OFF LIMITS AREA: Master Bedroom, two (2) Bedrooms upstairs, Upstairs Bathroom, Side portion of Backyard and Garage
ISOLATION AREA: Living Room

The facility is a two story home rented by the Licensee. The inside of the home was observed to be neat and clean with ample age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there no firearms and no pets in the home.

The home has one (1) fully charged 3A40BC fire extinguisher in the kitchen. There is one (1) working smoke detector in the family room and living room and one working carbon monoxide detector in the kitchen. The pull-down alarm is located on the wall in the dining room. The home is equipped with central heating and air conditioning for proper ventilation.

Continued on 809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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: BAWAZIR, FATIMA
FACILITY NUMBER: 015700183
VISIT DATE: 09/10/2021
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The Licensee’s Health and Safety training has been completed. Licensee’s Pediatric CPR & First Aid training is expired as of 5/2021. LPA discussed CPR & First Aid regulations (see LIC809-D). Licensee’s Mandated Reporter training is complete and expires on 1/28/2022. All required forms are posted and visible for public view in the entry way on the home.

LPA obtained a sample of the children’s files and the facility roster. Four (4) children’s files were incomplete and Facility roster was complete. LPA obtained the fire drill log which was completed. Last drill was logged on 4/18/2021.

Licensee was reminded that California Law requires licensees 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 email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

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SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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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: BAWAZIR, FATIMA
FACILITY NUMBER: 015700183
VISIT DATE: 09/10/2021
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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.

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.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2021 04:55 PM - It Cannot Be Edited


Created By: Morgan Pringle On 09/10/2021 at 04:35 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: BAWAZIR, FATIMA
FACILITY NUMBER: 015700183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021

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 record review the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2021
Plan of Correction
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Licensee will register for a Pediatric CPR & First Aid training and submit proof of registration to LPA.
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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021


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