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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406522
Report Date: 04/28/2026
Date Signed: 04/28/2026 05:18:22 PM

Document Has Been Signed on 04/28/2026 05:18 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 SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SIDDIQUE, AFSHANFACILITY NUMBER:
073406522
ADMINISTRATOR/
DIRECTOR:		SIDDIQUE, AFSHANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 432-0030
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
04/28/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Afshan SiddiqueTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
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On April 28, 2026 3:15pm, Licensing Program Analyst (LPA) Julia Placencia arrived at the facility unannounced to conduct an Annual/Random Inspection. LPA met with licensee Afshan Siddique. Also residing in the home is the licensee’s husband Affif and son Ammar. The facility is a two-story house. Hours of operation for child care are Monday through Friday, 8:00am to 5:00pm. The following was observed during today’s inspection:

Capacity/Staffing: The facility operates as a Family Child Care Home (large), which may have a maximum capacity of twelve (12) to fourteen (14) children. At time of inspection, there were eight (8) children in care (two infants and six preschoolers). The facility is in compliance with ratio and capacity limitations.

ON Limit areas (accessible to children in care): Entire home is on limits, however, the main child care area is the lower level which includes a side patio. Children only walk through the main floor to get from the front door to the stairs to child care area on lower level. There are child safety gates at the top and bottom of stairs. LPA observed the facility to be clean and in good repair, with heating and ventilation for safety and comfort. There were ample age appropriate toys that were observed to be safe and in good condition. The side yard play area is enclosed by fences. Entry to the outside play area is through the downstairs bathroom. There are no swimming pools, ponds or other bodies of water. LPA did not observe any dangerous conditions, nor any hazardous or toxic items accessible to children in the ON Limit areas of the facility today.


***Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Julia Placencia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SIDDIQUE, AFSHAN
FACILITY NUMBER: 073406522
VISIT DATE: 04/28/2026
NARRATIVE
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OFF Limit areas (not accessible to children in care): Exercise Room on bottom floor, Garage, backyard beyond children's play area including decks and stairs on lower and upper levels. OFF Limit areas are inaccessible by closed and/or locked doors and visual supervision. Licensee is advised to contact Licensing so that an inspection can be completed prior to changing an OFF Limit area to ON Limit.

Emergency Preparedness/Safety: Facility has a fully charged 3A40BC fire extinguisher. Smoke and carbon monoxide detectors were tested and found to be functioning. First aid supplies are available. Fire/disaster drills are conducted monthly and the last drill was on 3/31/26. Facility has phone service. Per licensee, there are no firearms in the home.

Staff Records Review: Licensee and all adults living and/or working in the home have proper criminal background clearances. Licensee's CPR/First Aid training expired on 4/14/26 and is registered for renewal on 5/3/26. Licensee has required immunizations and her mandated reporter training expires 8/19/26.

Children’s Records Review: Children's files were reviewed. Licensee maintains a sleep log for infants up to 24 months. Facility does not have Liability Insurance and Affidavits are in each child’s file. A facility roster is maintained.

Licensing Posting (required): Facility license, Notification of Parents’ Rights, Earthquake Preparedness, Emergency Disaster Plan.

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.



Licensee 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.

***Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Julia Placencia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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 SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SIDDIQUE, AFSHAN
FACILITY NUMBER: 073406522
VISIT DATE: 04/28/2026
NARRATIVE
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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-andresources/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.



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/.

Licensee 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, licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The following deficiencies were observed during today's inspection:
  • Helper present today does not have proof of mandated reporter training and measles/pertussis immunizations.

See LIC809D for deficiencies cited during today's inspection. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected. ***Please see LIC 9102 for Advisory Notes.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with licensee Afshan Siddique.
NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Julia Placencia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2026 05:18 PM - It Cannot Be Edited


Created By: Julia Placencia On 04/28/2026 at 04:51 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: SIDDIQUE, AFSHAN
FACILITY NUMBER: 073406522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, helper present today has not completed mandated reporter training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2026
Plan of Correction
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Licensee shall ensure helper completes her mandated reporter training for "child care providers" and submit copy of certificate to LPA by due date of 06/02/2026.
***Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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 record review, helper present today does not have proof of measles and pertussis on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2026
Plan of Correction
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Licensee shall ensure helper obtains proof of her measles and pertussis and submit copy of records to LPA by due date of 06/02/2026.
***Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jason Jang
NAME OF LICENSING PROGRAM MANAGER:
Julia Placencia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2026


LIC809 (FAS) - (06/04)
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