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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400656
Report Date: 03/28/2023
Date Signed: 03/28/2023 12:12:45 PM

Document Has Been Signed on 03/28/2023 12:12 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:SHAMSIDDEEN & WILLIAMS FAMILY CHILD CAREFACILITY NUMBER:
198400656
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/28/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Applicants, Naimah Shamsidden & Christopher Williams TIME COMPLETED:
12:30 PM
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On March 28, 2023 at 10:05 am, Licensing Program Analyst (LPA) Susann Sanchez conducted an announced
prelicensing inspection to the above facility. LPA met with Applicants Naimah Shamsidden & Christopher Williams who guided analyst on a tour of the facility. The Licensee is requesting to operate a Small Family Day Care Home. The operating hours would be Monday through Sunday from 12:00 AM to 11:59 PM. The applicants are applying to care for children ages: 6 weeks to 12 years old. Pre-licensing Entrance Checklist (LIC 9280) was provided to the Licensee upon arrival. Individuals residing in the home were discussed and noted.

All areas in the facility sketch were inspected during today's visit. This is a one story home. The home consist of 2 bedrooms, 2 bathrooms, classroom, sleep room, living room, dining room, kitchen, garage, backyard and front yard. Areas "off limit" to parents and children include: 2 bedrooms, 1 bathroom, kitchen, garage, front and backyard (temporary). Children and parents will use: living room, dining room, kitchen, sleep room, classroom, 1 bathroom, and backyard.

Areas used by children were inspected for safety, comfort, heating, cleanliness and telephone service. The home has central heating and air conditioning Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are made inaccessible and are kept in the garage. Applicants was advised that if any poisons are purchased, it is required to be locked with a key or combination lock.

Per applicants, there are no pets, firearms, weapons or bodies of water on the premises. LPA observed age appropriate toys and napping equipment for children. LPA observed electrical outlet covers throughout the facility. Smoke and carbon monoxide detectors were tested and are operable. A First Aid kit and emergency supplies are available. The applicants was advised that if food is brought from the children’s home, all containers must be labeled with the child’s name and properly stored or refrigerated.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: SHAMSIDDEEN & WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 198400656
VISIT DATE: 03/28/2023
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LPA observed the required fire extinguisher that is fully charged but it was not the required 2A10BC. Per Applicants will purchase the required size. Applicants was informed to have the fire extinguisher serviced yearly.

Applicants has proof of pediatric First Aid/CPR certification and expires April 2024. Applicant has submitted proof of immunization against pertussis and measles. Applicants has a declination for influenza on record. Applicant completed the required Preventative Health and Safety training, including the Nutrition and Lead components, and Mandated Reporter training (AB 1207). Applicant was advised that the mandated reporter training must be completed every 2 years and is available at www.mandatedreporterca.com.

Children will take walks to Mills Park for outdoor play. Currently the backyard is not available for outdoor play due to recent storms which have knocked over the outdoor furniture. Children will play in the backyard in the near future when the backyard is fixed. The backyard was observed to be fence.

LPA reviewed the following: infants need to sleep where they can be directly supervised at all times and advised against sleeping infants in a separate room. LPA provided the applicant with a copy of Provider Information Notice (PIN) 20-24-CCP and the Individual Infant Sleeping Plan (LIC 9227) to the applicants. LPA discussed the safe sleep regulations with applicant 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 applicant 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: http://www.ada.gov/childqanda.htm

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: SHAMSIDDEEN & WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 198400656
VISIT DATE: 03/28/2023
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PINs), Program Quarterly Update Newsletters and other important information communication platform. LPA provided assistance to the applicant on how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
Corrections made during today's inspection:
  • Application- Hours
  • LIC 279B
Items collected during collected:
  • LIC 9182
  • Copy of Applicants Measles
Corrections needed:
  • 2A10BC fire extinguisher
Corrections due date: 04/11/2023

LPA provided the Forms and Records to Keep in your Family Child Care Home (LIC 311D). Per applicant, there are no dual licenses at this address. Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information.
Also discussed during inspection and consult was given for:
  • 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, TB clearance, immunization, Mandated Reporter training certificate www.mandatedreporterca.gov, and a valid criminal record clearance associated to the facility license.
  • -A current roster of children enrolled must be available and maintained for a period of three years, even after children are no longer attending the facility.
  • -Unusual incident or any changes will be reported to Licensing within 24 hours and an LIC 624B will be submitted within 7 days.

Once corrections are submitted, a final review of the application will be conducted by the Department. Once licensed, the applicants is required to adhere to the terms and limitations stated on the license. Exit interview conducted and report was reviewed with the applicants N. Shamsiddeen & C. Williams.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC809 (FAS) - (06/04)
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