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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624067
Report Date: 09/30/2021
Date Signed: 09/30/2021 11:47:02 AM

Document Has Been Signed on 09/30/2021 11:47 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:ABDUL QADIR, JAMILAHFACILITY NUMBER:
343624067
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/30/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jamilah Abdul QadirTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Michelle Pascual met with applicant, Jamilah Abdul Qadir for the purpose of a pre-licensing visit. Present was the applicant's husband, all individuals have fingerprint clearances.

A health and safety inspection was conducted inside and out. The three story house consists of a family room, bedroom and bathroom on the first floor, a kitchen, nook, dining area and living room on the second floor (entry floor) and three bedrooms and two bathrooms on the third floor. Off limit areas is the entire second floor (except foyer for drop off) and the third floor. Gates are blocking access to these areas. The garage is also off limits. Off-limits areas will remain inaccessible to children through supervision. The applicant acknowledges that she must contact LPA prior to making an off-limits area on-limits and vice versa. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detectors and a 3-A10BC fire extinguisher were observed in the home. There are no bodies of water on the premises and no firearms. Applicant knows that 100% supervision must be provided when children are playing outside in the back yard.

LPA verified current in-person EMSA pediatric CPR (exp 11/2021) and First Aid certification. Mandatory Reporter Training has not been completed and will be completed ASAP. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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: ABDUL QADIR, JAMILAH
FACILITY NUMBER: 343624067
VISIT DATE: 09/30/2021
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Incidental Medical Services (IMS) policy was discussed. Applicant will provide an IMS plan to the LPA as IMS are being provided. 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

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. Their signature on this form acknowledges receipt of this form.


Licensure is pending the completion of the following items:

1. Mandatory Reporter Training by the licensee
2. A cover for the Fireplace to prevent accidents.

Once received LPA will license the facility for a small family childcare.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC809 (FAS) - (06/04)
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