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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623694
Report Date: 09/01/2021
Date Signed: 09/01/2021 12:14:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/01/2021 12:14 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:SAMAHA, JASMINEFACILITY NUMBER:
343623694
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jasmine SamahaTIME COMPLETED:
12:30 PM
NARRATIVE
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On September 1, 2021 at 11:00 AM, Licensing Program Analyst (LPA) Alize Tillery met with licensee Jasmine Samaha for the purpose of a request for increase in capacity and annual required 1 year inspection. The facility’s days and hours of operation are Monday - Friday from 7:30 AM to 5:30 PM. Only licensee and licensee’s 4 year old son was present during today’s inspection. All individuals subject to criminal background review have obtained a criminal record clearance.

A health and safety evaluation was conducted in all areas accessible to children. Off limit areas consist of: bedroom #2, the garage, the shed and the back house. Licensee is aware that children are to never enter these off limit areas.

LPA observed a 2A10BC fire extinguisher, first aid kit and functioning smoke and carbon monoxide detectors. Per licensee, there are no weapons in the home. No children were observed in parked cars. Toxic and hazardous items are inaccessible to children and safe toys were observed.

During today’s inspection, LPA observed 4 children’s files; all files observed were complete. LPA reviewed staff and facility files; LPA observed all required documents. LPA discussed capacity requirements with Licensee. Required postings and the children’s roster were observed. Licensee has record of conducting fire drills at least every six months. Per record, last drill was conducted on 06/30/2021. LPA recommended COVID19 posters and current guidelines were discussed. LPA observed licensee’s CPR and First Aid card which is current and expires 04/24/2023.

Continued on LIC809C…
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: SAMAHA, JASMINE
FACILITY NUMBER: 343623694
VISIT DATE: 09/01/2021
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LPA discussed the requirement of renewing mandated reporter training every 2 years. Licensee’s Mandated Reporter Training is current and expires on 8/23/2023. LPA provided a list of documents that are to be kept in the assistant’s file.

Licensee does not currently provide Incidental Medical Services (IMS). For IMS information, licensee was advised to see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

LPA discussed Safe Sleep in Child Care. LPA provided the following link:http://www.cdss.ca.gov/inforesources/Community-Care-Licensing/subscribe for the Licensee to subscribe to the distribution list and receive Quarterly Updates. Licensee was informed that a play yard or crib is required for each infant in care and a copy of the infant regulations was printed out and provided during the inspection.

During today’s inspection, in the areas that were observed, there were no deficiencies cited. This facility evaluation report was reviewed and discussed with the licensee. A notice of site visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of 3 years for public review upon request.

As of today, September 1, 2021, the facility is licensed to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or elementary school and 1 child at least age 6 with a maximum of 3 infants. Infants are children ages 0-23 months.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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