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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624549
Report Date: 10/26/2022
Date Signed: 10/26/2022 11:33:30 AM

Document Has Been Signed on 10/26/2022 11:33 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:FAIZI, PALWASHAFACILITY NUMBER:
343624549
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
10/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Faizi, Palwasha TIME COMPLETED:
11:50 AM
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On Wednesday, October 26, 2022, at approximately 10:40 AM, Licensing Program Analyst (LPA) Alize Tillery met with Applicant Palwasha Faizi for the purpose of an announced pre-licensing inspection. During today’s visit, applicant, her spouse and their minor child was present in the home. Applicant and all other adults residing in the home have a criminal record clearance. Applicants primary language is Pashto, Applicant’s family friend Mohammad Dariq Mullahkhil assisted in translating between LPA and applicant during today’s visit. Applicant plans to operate Monday – Friday from 8:00 AM to 8:00 PM.

A health and safety inspection was conducted inside and outside the home. The home includes 4 bedrooms, 3 bathrooms, living room 1 and living room 2, garage, laundry room and a fenced back yard with a shed. Off-limit areas will include: entire upstairs, garage, kitchen and the shed in the backyard. Applicant understands that children may never enter these off-limit areas.



There is a fireplace in the home that in not operational. 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. Children’s medications will be stored in the kitchen, out of children’s reach. A functioning smoke detector, carbon monoxide detector and a full 2A10BC fire extinguisher was observed in the home. LPA observed all required licensing postings. COVID19 guidelines were discussed.

Applicant Palwasha Faizi completed the required Preventative Health and Safety course and the Lead Poisoning Prevention in June 2022, and EMSA certified CPR and First Aid training on 08/06/2022. Applicant’s CPR certificate will expire in 08/2024. Applicant is exempt from the Mandated Reporter training due to language barrier. Applicant is aware that the CPR training is to be renewed every two years. Applicant stated there are no weapons in the home. There are no bodies of water on the premises. Applicants were encouraged to maintain supervision at all times. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed.

Report continues on LIC809-C.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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: FAIZI, PALWASHA
FACILITY NUMBER: 343624549
VISIT DATE: 10/26/2022
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Applicant was reminded that all adults 18 and over living or working in the home, 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.

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 October 26, 2022 facility is approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only; or up to 8 children with no more than 2 infants, with 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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