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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400656
Report Date: 10/01/2024
Date Signed: 11/20/2024 08:52:10 AM

Document Has Been Signed on 11/20/2024 08:52 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:SHAMSIDDEEN & WILLIAMS FAMILY CHILD CAREFACILITY NUMBER:
198400656
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 2CENSUS: 3DATE:
10/01/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:NAIMAH SHAMSIDDEEN / LICENSEETIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced random / annual inspection to the above facility. LPA met with Licensee Naimah Shamsiddeen & Christopher Williams who guided analyst on a tour of the facility.

The Licensee operates a Small Family Day Care Home. The operating hours are be Monday through Sunday from 12:00 AM to 11:59 PM (weekends available if needed). The licensee cares for children ages: 6 weeks to 12 years old. Entrance Checklist (LIC 9280) - Family Child Care Homes was provided to the Licensees' upon arrival. Per Licensees' home is a rental and uses LIC282 Affidavit Regarding Liability Insurance form. LPA observed 2 children in care upon arrival.

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 yard. Children and parents use: living room, dining room, sleep room, classroom, 1 bathroom, and backyard.

Currently backyard is not in use due to Licensee interest in applying for a Large Family Child Care Home, this was reported to Licensing 9/25/24. Licensee's stated backyard is being changed to add soft artificial grass/turf and Licensee Williams is working on remodeling the backyard. LPA observed that there were no bodies of water on the premises.

Areas used by children were inspected for safety, comfort, heating/ ventilation, 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 or in off limit kitchen (baby gate in place / baby latches). Poisons are locked in the garage. Licensee's are aware to lock poisons. (Page 1 / Continuation...)
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: SHAMSIDDEEN & WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 198400656
VISIT DATE: 10/01/2024
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Per Licensees', there are no pets or firearms, weapons. LPA observed age appropriate toys and napping equipment for children. Smoke and carbon monoxide detectors were tested and are operable. Fire place was observed to have a screen and barricaded of for inaccessibility. Per Licensee, fire place gas is shut off and fire place does not work.

LPA observed the required fire extinguisher that is fully charged and purchased within in one year. LPA consulted with Licensee that the fire extinguishers can be serviced and inspected yearly or have proof of receipt. Disaster and Fire Drill was conducted drill on 10/2024.

Licensee stated provides food for the children. Licensee's 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. Kitchen was observed to have baby gate for inaccessibility.

Per Licensee, children who show signs of illness waiting to be picked up are waiting in dining room or in one of the rooms used for day care depending on the number of children in care.

LPA reviewed (2) children's records and both Licensees' records. Infant children's 15 min sleep log was observed to be inconsistent, LPA gave consultation. Both Licensees' mandated reporter training and pediatric first aid and cpr was reviewed and observed to be expired, deficiency noted. LPA provided consultation on Records organization and LIC311D was used and provided. At 12:00pm additional child arrived making census 3. LPA conducted staff interview.

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. (Page 2/ Continuation...)
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: SHAMSIDDEEN & WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 198400656
VISIT DATE: 10/01/2024
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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.

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.

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, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Based on today’s visit, Per Title 22 regulation there were (2) deficiencies cited, Type B, provided on LIC 809-D.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Naimah Shamsidden. (End Report)

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 08:52 AM - It Cannot Be Edited


Created By: Ashley Calderon On 10/01/2024 at 12:51 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SHAMSIDDEEN & WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 198400656

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
(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 Licensees' pediatric first aid and cpr expired 4/2024 for Licensee Williams and Shamsiddeen, the licensee did not comply with the section cited above in [2] out of [2] persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensees' will take pediatric first aid and cpr class, send renewed certification to LPA Calderon by poc due date.
Type B
Section Cited
HSC
1596.8662(b)(1)
(b) (1)   On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child 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 mandated reporter certification for Licensee's Williams and Shamsiddeen, the licensee did not comply with the section cited above in [2] out of [2] persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensees' will take mandated reporter training, LPA Calderon provided link. Licensee will send mandated training certificate to LPA by poc due date.
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:Valarie Cook
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


LIC809 (FAS) - (06/04)
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