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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623694
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:22:07 PM

Document Has Been Signed on 06/20/2023 03:22 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAMAHA, JASMINEFACILITY NUMBER:
343623694
ADMINISTRATOR:SAMAHA, JASMINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 287-1235
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
06/20/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Jasmine SamahaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Gagandeep Singh met with licensee, Jasmine Samaha, for an annual inspection. The purpose of the inspection was explained. Licensee lives in a single story story home. During inspection, there are ten day care children in care with licensee and one helper. All adults living or working in the home have criminal background check on file. Licensee is operating within the capacity of this date. Licensee provides day care from Monday to Friday between 7:30 AM to 5:30 PM.

LPAs inspected the day care areas with the licensee. Day Care Areas: Living room, Kitchen, Hallway, Bedroom in the hallway, Bathroom in hallway, Back yard. Off limit areas: Master bedroom, Bedroom # 2 and Garage. There is no pool, spa or any other body of water in the house. As per licensee, there is no firearm or weapon in the house. All the cleaning supplies, poisons and other chemicals are stored inaccessible to the children. The house is in good repair and free of hazards with proper temperature and ventilation. There is carbon monoxide detector, smoke detector, fully charged fire extinguisher and working telephone available in the house. There is a variety of age appropriate toys in the house. Licensee has five cribs in the house for the infants.

LPA reviewed the facility records. LPA observed licensee has License and other required documents posted in the child care areas. Licensee has record of training of preventive health and CPR card valid until April 30, 2025. LPA observed that licensee has a log in place for fire and emergency drills and per log, last drill was conducted on May 31, 2023. Licensee has an updated children roster on file. Licensee has the sleep logs in place for each infant in care.

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SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SAMAHA, JASMINE
FACILITY NUMBER: 343623694
VISIT DATE: 06/20/2023
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LPA also reviewed the enrolled children's record. LPA reviewed the identification and emergency information form for every child for proper names and numbers filled. Licensee has record of immunization of each child in care. LPA discussed the safe sleep regulations and provided a copy of PIN 20-24-CCP.

Licensee is aware that all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. LPA observed licensee has completion certificate on file and per certificate, the training is valid until August 23, 2023.

LPA reminded the licensee that all adults, 18 years and older living in the home, helper or assistant must have criminal record clearance and must be associated to the facility by submitting an LIC 9182 prior to having any contact with children in care. Failure to do so could result in an immediate civil penalty of $100.00 each day.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

LPA encourage the licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.



No deficiencies cited today. The copy of this report is reviewed and provided to the licensee. Notice of site visit is posted and shall remain posted for next 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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