343624293-5-12-2022-03-CC-MPAL-CECT9X-20220512143238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624293
Report Date: 05/12/2022
Date Signed: 05/12/2022 02:32:46 PM

Document Has Been Signed on 05/12/2022 02:32 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:	MOHAMMADI, SHARIFA		FACILITY NUMBER:	343624293
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	05/12/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Sharifa Mohammadi		TIME COMPLETED:	11:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michelle Pascual met with applicant Sharifa Mohammadi, spouse & son for the purpose of an announced pre-licensing inspection on May 12th, 2022. All adults are fingerprint cleared. A health and safety inspection was conducted inside and out. The two - story house has 4 bedrooms, 2 bathrooms upstairs and a laundry room. The downstairs has the kitchen, front room and family room with a half bathroom. OFF LIMITS AREAS: The entire upstairs area and the kitchen. 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 were witnessed and tested. Applicant has the appropriate size fire extinguisher. There are no bodies of water on the premises. Applicant knows that 100% supervision must be provided when children are playing outside. Medications and toxic items are stored and locked away as well as knives and sharp items in the kitchen and out of reach.

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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: MOHAMMADI, SHARIFA	FACILITY NUMBER: 343624293
	VISIT DATE: 05/12/2022

NARRATIVE

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Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, 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. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA verified current in-person EMSA pediatric CPR and First Aid certification as well as mandatory Reporter. Expiration of CPR is 8/2023.

Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed.

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

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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: MOHAMMADI, SHARIFA	FACILITY NUMBER: 343624293
	VISIT DATE: 05/12/2022

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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.

LPA reviewed with licensee the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the licensees Sharifa Mohammadi

Effective today: May 12th, 2022 licensed for 6 children with no more than 3 infants,

or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC809 (FAS) - (06/04)

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