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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402110
Report Date: 03/22/2023
Date Signed: 03/24/2023 08:18:28 AM

Document Has Been Signed on 03/24/2023 08:18 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:TAKESHI, EZATFACILITY NUMBER:
073402110
ADMINISTRATOR:TAKESHI, EZATFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 952-4849
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 6DATE:
03/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ezat TakeshiTIME COMPLETED:
12:30 PM
NARRATIVE
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On 3/22/23 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Required 1 Year Inspection at Ezat Takeshi's Large Family Child Care Home. LPA met with Licensee, Ezat and explained the purpose of today’s inspection. LPA was granted permission to enter the facility. Present in the home were Licensee, 1 Assistant and 6 day care children (2 infants, 4 preschool age). Facility is in compliance with required ratios today. Days and hours of operation are Monday - Friday from 8:30am - 4pm. Licensee's spouse was also present in the home. Adults present have Criminal Background Check Clearances,
INDOOR AREA: Home is single floor.
In Use Areas: Garage converted into Playroom, 1 Nap Bedroom (on right side of hallway), 1 Bathroom (in hallway near kitchen)
Off Limit Areas: Living room, Kitchen/Dining, all other 2 bedrooms and 2 bathrooms
Garage has been converted into Playroom, with an exclusive side entrance, separate from main entrance to home. Children walk through the Kitchen/Dining area to reach the bathroom. There were no accessible dangerous items observed in the kitchen/dining areas. LPA observed sufficient materials, toys, and play equipment for the day care children in the home. Children were engaged in various activities under the supervision of the Licensee and Assistant All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Furniture and equipment, such as cribs, mats, feeding chairs, and tables were age appropriate and in good condition. There were no baby walkers, jumpers or bouncers observed on the premises during today’s inspection. The home is sanitary, orderly, and safe for the day care children. There is no fireplace or stairs inside the home. LPA observed a fully charged fire extinguisher and working smoke / carbon monoxide detectors. The Licensee states that she does not have any weapons or pets in the home. LPA reviewed a current Children Roster. Licensee states last fire drill was conducted in February 2023 but did not maintain a Fire Drill Log. Emergency Disaster Plan LIC610A was not posted or available for review. Parent Rights Poster was not posted. Licensee states that she does not transport children. She supplies snacks and meals . Food storage area was observed to be clean. Supervision of children was discussed with the Licensee and she understands that she must be present in the home during 80% of the operating hours of the day care and ensure that the children are supervised at all times.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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 6
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: TAKESHI, EZAT
FACILITY NUMBER: 073402110
VISIT DATE: 03/22/2023
NARRATIVE
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OUTDOOR space was inspected. A small area right outside the Play Room is dedicated for outdoor activities. It is fenced and separated from the home's main backyard. Play equipment was observed to be maintained in safe condition and free of hazards. The yard was fenced and there were no bodies of water.
FILE REVIEW: Children, Licensee, Assistant files reviewed, contained all required documents. Licensee’s Mandated Reporter Training and certifications for CPR/First Aid is current.

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
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 does not maintain a Sleep Log but states she checks on infants every 15-20 minutes, keeps bedroom door open. 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.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/24/2023 08:18 AM - It Cannot Be Edited


Created By: Monica Mathur On 03/22/2023 at 10:53 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: TAKESHI, EZAT
FACILITY NUMBER: 073402110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee failed to provide a copy of Emergency Disaster Plan LIC610A for review. LPA did not see it posted.
POC Due Date: 03/29/2023
Plan of Correction
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LPA provided a blank copy of the form. Licensee agreed to
1. send a copy to Licensing
2. readily available for review during inspections moving forward
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:Sherelle Johnson
LICENSING EVALUATOR NAME:Monica Mathur
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/24/2023 08:18 AM - It Cannot Be Edited


Created By: Monica Mathur On 03/22/2023 at 10:53 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: TAKESHI, EZAT
FACILITY NUMBER: 073402110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee does not have documentation for safety drills.
POC Due Date: 03/22/2023
Plan of Correction
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She agreed to maintain a drill log moving forward. LPA provided a copy of Log. Licensee filled it out and posted on wall. Deficiency was cleared today.

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:Sherelle Johnson
LICENSING EVALUATOR NAME:Monica Mathur
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/24/2023 08:18 AM - It Cannot Be Edited


Created By: Monica Mathur On 03/22/2023 at 10:53 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: TAKESHI, EZAT
FACILITY NUMBER: 073402110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee states she does not maintain a Sleep Log for infants.
POC Due Date: 03/29/2023
Plan of Correction
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She will start maintaining a Log immediately. LPA provided a copy of Sleep Log
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:Sherelle Johnson
LICENSING EVALUATOR NAME:Monica Mathur
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: TAKESHI, EZAT
FACILITY NUMBER: 073402110
VISIT DATE: 03/22/2023
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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.

In the areas that were evaluated, regulatory violations were observed. Citations are issued on 809-D pages of this report. LPA provided print outs of Emergency Disaster Plan, Parents Rights Poster, Sleep Log, Safe Sleep Frequently Asked Questions, Fire Drill Log. Exit interview conducted and report was reviewed with the Licensee. A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC809 (FAS) - (06/04)
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