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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494967
Report Date: 06/01/2022
Date Signed: 06/01/2022 11:58:52 AM

Document Has Been Signed on 06/01/2022 11:58 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:SHAMSUDDIN & SHAMSUDDIN FAMILY CHILD CAREFACILITY NUMBER:
197494967
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
06/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tabinda& Karim ShamsuddinTIME COMPLETED:
12:00 PM
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On June 1,2022 Licensing Program Analyst (LPA) Doris Whitmore conducted an announced inspection with applicants Tabinda Shamsuddin & Karim Shamsuddin, for the purpose of a pre-licensing inspection of 4275 Kenyon Ave Los Angeles CA 90066. The purpose of this inspection is to ensure the standards for a Family Child Care Home are being met in accordance to California Title 22 Regulations and California Health and Safety Codes.

The applicants is applying for a Small family childcare license with a max capacity of 8. Property owner/landlord consent (LIC 9149) is currently on file. The license rents /leases property with adult Karim Shamsuddin. And two children control of property is on file. Residents of the home are the applicant, applicant’s spouse, mother and two children (ages 15 & 11).

Applicant wishes to care for children 1 yr. to 5-years with the hours of operation of hours 8:00a.m. to 5: 00p.m. Monday- through Friday. Applicant was informed that any changes to ages, hours, days of operation shall be submitted to the department for approval prior to initiation of changes.

The home is a two-story home with upstairs and downstairs. The day care will be downstairs upstairs will be off limits to the children in care. Total bedrooms are six. Three bedrooms upstairs and three bedrooms downstairs.

Upstairs Entry into the home is via the front door. Upstairs consist of a Livingroom, dining room, kitchen, bedrooms, and the Laundry room observed is outside on the patio. The Living Room was observed with one couch. Across from the living room is the dining room with a couch and a cabinet against the wall. In the dining area there is a TV Mounted to the wall. As you walk down the hallway there is a door that opens to the patio which is off limits.

Upstairs The kitchen was observed with a refrigerator and countertop no knives on the countertop

Room #1 upstairs is the applicant daughter room which was observed and did not have any items observed risk to children in care. During operation hours doors will be locked. There is a door to the left that are stairs that leads to the bottom of the house. Page 1

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SHAMSUDDIN & SHAMSUDDIN FAMILY CHILD CARE
FACILITY NUMBER: 197494967
VISIT DATE: 06/01/2022
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Room #2 upstairs is the applicant’s other daughter room was observed and did not have any items observed risk to children in care.

Room#3 upstairs is the applicant mother’s room which was observed and did not have any items observed risk to children in care.

All bathroom’s upstairs are in the bedrooms with a shower, sink, and toilet and did not have any toxins, medications, or chemicals that would pose a risk to children in care.

Downstairs is where the main day care with be the applicant had a 2-ABC Fire Extinguisher, one dual smoke detector /carbon monoxide that was tested. First Aid was missing tweezers, thermometer, and scissors. Entrance of day care is on the lower floor parents will bring children to the backgate where there is a table to sign children in and the Parent Board. Parent Board was up without any postings. The room for the main day care has a door that leads to the outdoor area with stairs that would need a safety gate. In the main room are the children cubbies. In the main room there is one drawer against the wall.

Room#1 Downstairs will be used for the children to nap. In the closet area there were exposed pipes that could be seen. In the room there was a crib and a pack play

Room #2 Downstairs will be used for additional children to nap with a small kitchen, the kitchen downstairs will only be used to store milk in the refrigerator. The room has a pack play and a changing table., and as safety gate to block off the kitchen area. Applicant sated that after a year

Room 3 is the applicant’s room which will remain lock during operating hours

All meals will be prepared upstairs in the kitchen for breakfast, snack and lunch.

Bathroom downstairs has one toilet and one bathroom with a shower. On the shower door is a lock to prevent access to the children in care. All cabinets were empty and did not have any toxins, medications or chemicals that would pose a risk to children in care. There is a bidet toilet for the children and the water will be turned off during operating hours. Page 2

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SHAMSUDDIN & SHAMSUDDIN FAMILY CHILD CARE
FACILITY NUMBER: 197494967
VISIT DATE: 06/01/2022
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Per the applicant there are no weapons or pets in the home, LPA did not observe any weapons or pets at the time of inspection.

For outdoor activity there is a backyard that has age appropriate toys that consist of a slide.

The FCCH will not provide Incidental Medical Services (IMS) policy was discussed.

·Applicant was reminded that all adults and over 18 living and 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 the regulation is violated

· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant

CPR& Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.

· A current roster of children enrolled must be maintained and available

· The fire extinguisher type 2A-10BC must be services annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced

· Reporting requirements: Applicant must report any unusual incidents or injuries to the Child Care Regional Office by telephone within 24 hours and in writing within 7 days

· LPA advised applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at www.ccld.ca.gov

Mandatory Forms for the children’s files and provider’s files were discussed. Applicant was referred to LIC311D. These forms were discussed and provide to the applicant at the time of inspection.



Prior to licensure the following will needs to be corrected by 06/13/2022:

Downstairs Kitchen add locks

First Aid Kit need tweezers, thermometer, & scissors

Add safety gate to the stairs that leads to the outdoor area

Barricade or cover the exposed pipes in room #1

Postings on the Parent Board

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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SHAMSUDDIN & SHAMSUDDIN FAMILY CHILD CARE
FACILITY NUMBER: 197494967
VISIT DATE: 06/01/2022
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The following was discussed:

Assembly Bill (AB) 633: Upon receipt by the licensee, licensees are to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this family child care home in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license. Copies of any of the above licensing documents the licensee has received in the prior 12 months shall be provided to parents/guardians of newly enrolled child at the facility.

Criminal Record Clearance. All adults who reside or work in the home must obtain a criminal record clearance or exemption.
Mandated Reporter: Applicant was made aware of AB 1207, commencing January 1, 2018, requires all licensed providers, Applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. Website: www.mandatedreporterca.com Health & Safety Code 1596.8662.
Shaken Baby Syndrome Awareness & Safe Sleep. Applicant was reminded never shake a baby to prevent Shaken Baby Syndrome. LPA discussed Safe Sleep Regulations with Applicant: one crib or play yard for each infant in care; cribs and play yards are kept free from all loose articles and objects while infants are sleeping; no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress, which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to

12 months of age are placed on their backs for sleeping. Applicant was also reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.


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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SHAMSUDDIN & SHAMSUDDIN FAMILY CHILD CARE
FACILITY NUMBER: 197494967
VISIT DATE: 06/01/2022
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Incidental Medical Services Awareness. Incidental Medical Services (IMS) policy was discussed. Facilities that provide Incidental Medical Services (IMS) must identify those services in their facility’s Plan of Operation and submit an updated Plan of Operation to the Department. Incidental Medical Services Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Emptying an Ileostomy Bag.

An exit interview was conducted. A copy of this report was discussed provided to applicant. Page 5
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
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