343624177-1-18-2022-03-CC-JGAG-CASPZC-20220118104519

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624177
Report Date: 01/18/2022
Date Signed: 01/18/2022 10:45:31 AM

Document Has Been Signed on 01/18/2022 10:45 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:	SAFI, JAMILA		FACILITY NUMBER:	343624177
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	01/18/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jamila & Jamil urahman Safi		TIME COMPLETED:	11:00 AM

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On Tuesday, January 18 2022, at approximately 9:45 AM, Licensing Program Analysts (LPAs) Josiah Gathing and Gagandeep Singh met with Applicant Jamila Safi and applicant’s husband for the purpose of conducting an announced change of location pre-licensing inspection. During today's inspection, applicant, her husband and their adult daughter were present in the home. Applicant’s first language is Pashto and her husband provided translation during the inspection. Applicant and all other adults have criminal record clearances on file. Applicant plans to operate Monday – Friday from 8:00 AM to 8:00 PM. Applicant submitted proof of control of property and landlord consent form. Applicant can care for up to 8 children.

A health and safety inspection was conducted inside and out of the home. The one-story facility includes 3 bedrooms, 2 bathrooms, kitchen, living room, family room, garage, an unfenced front yard and fenced backyard. The Off-limits areas include: bedroom #2, bathroom #2, kitchen, and garage. Licensee acknowledged that children may never enter these off-limit areas.

The fireplace is covered with a gate. Toxic and hazardous items are inaccessible to children and out of children's reach. Sharp knives are stored in the kitchen out of children's reach. Applicant will have medications stored in the kitchen, out of children’s reach. A first aid kit, functioning smoke detectors, a carbon monoxide detector and a full 2A10BC fire extinguisher were observed in the home. LPAs observed all required licensing postings along with COVID19 posters.

Report continues on LIC809-C.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

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: SAFI, JAMILA	FACILITY NUMBER: 343624177
	VISIT DATE: 01/18/2022

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LPA discussed Unusual Incident Report requirements with applicant. Applicant completed the required Preventative Health and Safety course and Applicant has a current EMSA certified CPR and First Aid card. Applicant is exempt from the Mandated Reporter Training due to the language barrier. Applicant's husband stated there are no weapons in the home and there are no bodies of water on the premises. Applicant understands that prior to making alterations or additions to the home or grounds, he/she shall notify the Department of the proposed changes.

Applicant was encouraged to visit the Department’s website at www.cdss.ca.gov for more information regarding child care updates, forms, regulations and legislation.

This application is pending approval from Supervisor.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

LIC809 (FAS) - (06/04)

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