343624365-6-16-2022-03-CC-JGAG-CFFTH8-20220616144418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624365
Report Date: 06/16/2022
Date Signed: 06/16/2022 02:44:23 PM

Document Has Been Signed on 06/16/2022 02:44 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:	MANSORI, KARIMA		FACILITY NUMBER:	343624365
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	06/16/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Karima Mansori		TIME COMPLETED:	02:50 PM

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On Thursday, June 16 2022, at approximately 1:20 PM, Licensing Program Analyst (LPA) Josiah Gathing met with Applicant Karima Mansori for the purpose of conducting an announced change of location pre-licensing inspection. During today's inspection, the applicant and minor child were present in the home. All adults living in the home have received criminal record background clearance. Applicant’s first language is Pashto and her child provided translation during today’s inspection. Applicant plans to operate Monday – Friday from 8:00 AM to 11:59 PM.

A health and safety inspection was conducted inside and out of the home. The single-story home includes 3 bedrooms, 2 bathrooms, dining room, living room, kitchen, garage, and fenced back yard. Off-limits areas: All 3 bedrooms, bathroom 2, living room, and garage.

Cleaning supplies will be stored in an area inaccessible to children. Sharp knives are stored in the kitchen out of children's reach. Multiple smoke detectors, a carbon monoxide detector, first aid kit, and a full 1A10BC fire extinguisher were observed in the home. Required documents were posted near the facility entrance.

Applicant is scheduled to complete the Preventative Health and Safety course including the Lead Poisoning Prevention training on 08/20/2022. Applicant has a current EMSA certified CPR and First Aid certificate which expires 01/08/2024. Applicant stated there are no weapons in the home. Applicant understands that prior to making alterations or additions to the home or grounds, 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.

Report continues on LIC809-C...

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

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: MANSORI, KARIMA	FACILITY NUMBER: 343624365
	VISIT DATE: 06/16/2022

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LPA discussed open door policy, supervision, fire drills, reporting requirements, and the smoking prohibition with the applicant. A current roster of children enrolled must be available and maintained for a period of three years, even after children are no longer in care. Annual fees must be paid promptly and by the due date or late fees will be assessed. Applicant understands that the license is non-transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected.

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 submitting 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 discussed the safe sleep regulations with Applicant 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 Director 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.

An exit interview was conducted with Applicant and Covid-19 protocols were discussed. LIC311D, records, postings, and reporting requirements were discussed. LPA discussed personal rights, criminal record clearances, ratios and capacity, and maintaining buildings and grounds. Applicant was encouraged to visit the Department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

As of today, June 16, 2022, this facility is approved for a provisional Small Family Child Care Home license for a capacity of 8 children with no more than 3 infants, or 4 infants only. Infants are children under the age of 2. Proof of completion of the Preventative Health and Safety training must be provided to LPA within 90 days to receive a permanent license.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC809 (FAS) - (06/04)

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