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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624549
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:55:37 PM

Document Has Been Signed on 09/26/2024 03:55 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FAIZI, PALWASHA & FAIZI, SAMIULLAHFACILITY NUMBER:
343624549
ADMINISTRATOR/
DIRECTOR:		FAIZI, PALWASHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 907-5860
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
09/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Palwasha FaiziTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On Thursday, 26 September, 2024, at approximately 12:30 pm, Licensing Program Analyst (LPA) Fabian Schwartz met with Licensee, Palwasha Faizi, for the purpose of an unannounced annual inspection. Upon arrival, LPA observed licensee supervising her own infant child. Also present at time of inspection were licensee’s 3 older children, 1 of which, Faiz Mohammed Faizi, is over 18 and provided translation services for licensee. Licensees primary language is Pashto. During time of inspection, Licensee Samiullah arrived to the facility. All individuals subject to criminal background review have obtained a criminal record clearance. LPA observed proper ratio and capacity was being followed. Facility hours of operation are Monday-Friday 8:00 am-8:00 pm. LPA verified that the annual fees are current.

A health and safety evaluation was conducted in all areas accessible to children. Facility is a 4 bedroom, 2 bathroom two story home. Off-limit areas include: Upstairs, Laundry Room, Garage, and Kitchen. Licensee acknowledged that children may never enter these off-limit areas. LPA observed that the facility is clean and sanitary. LPA observed a functioning smoke detector and a full 2A10BC fire extinguisher. LPA observed 2 Carbon Monoxide detectors, neither of which were operational. The facility has adequate toys that appear to be safe for children to use. The licensee stated there are no weapons or poisons in the home. LPA observed that there is a fenced backyard with no pool. Backyard fence has plank which is broken and creates a hole large enough for a child to fit in. The sideyard gate which connects the backyard to the front yard was observed to be screwed closed and LPA could not open gate. Backyard contained a permanent construction shed with no door which was being used as a storage location for old tools. Inside there was broken glass and a sharp saw which are accessible to children.


PAGE 1. REPORT CONTINUES ON LIC809-C
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Fabian Schwartz
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FAIZI, PALWASHA & FAIZI, SAMIULLAH
FACILITY NUMBER: 343624549
VISIT DATE: 09/26/2024
NARRATIVE
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LPA reviewed 8 children’s files, none of which were observed to be complete. All files were missing a completed LIC-700. 4 children in care had no files at facility. Required postings were seen to the right of the entrance door, and the children’s roster was observed. LPA did not observe infant sleep plan (LIC 9227) or 15-minute observation checks for napping infants. The facility does not have a record of conducting fire drills at least every 6 months. Licensee Palwasha’s CPR/First Aid card expired on 6 Aug 2024. Licensee Samiullah’s CPR/First Aid card expires on 1 Dec 2025. Licensee’s did not have Mandated Reporter certificates due to training not being offered in their primary language. Licensee understands that trainings must be completed every two years.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.


PAGE 2. REPORT CONTINUES ON LIC809-C
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Fabian Schwartz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FAIZI, PALWASHA & FAIZI, SAMIULLAH
FACILITY NUMBER: 343624549
VISIT DATE: 09/26/2024
NARRATIVE
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days. Based on the inspection, 2 Type A and 5 Type B Title 22 deficiency citations have been issued. The Type A deficiencies are for not having a working Carbon Monoxide Detector, and for having dangerous items accessible in backyard shed. The Type B Deficiencies are for having a broken backyard fence, not maintaining a fire drill log, missing children’s files, licensee Palwasha having an expired CPR card, and for not maintaining Infant sleep logs or having Individual Infant Sleeping Plan for infant in care.

Title 22 deficiencies are cited on the subsequent pages of this report. Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the Licensee. LIC 9224 and Appeal Rights were provided. Licensee's signature on this report acknowledges receipt of these rights.

Exit interview conducted and report was reviewed with the licensee. During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Appeal Rights were provided.

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Fabian Schwartz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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Page: 3 of 7
Document Has Been Signed on 09/26/2024 03:55 PM - It Cannot Be Edited


Created By: Fabian Schwartz On 09/26/2024 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FAIZI, PALWASHA & FAIZI, SAMIULLAH
FACILITY NUMBER: 343624549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensees did not comply with the section cited above by not having a working carbon monoxide detector during time of inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensees will obtain a functioning Carbon Monoxide detector by 27 September 24 and send LPA Schwartz video of carbon monoxide detector test beeping.
Type A
Section Cited
CCR
102417(g)(4)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensees did not comply with the section cited above by having a saw and broken glass accessible to children in backyard shed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensees will remove all dangerous items from shed and show LPA evidence that it has been removed by 27 September 24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Amanda Blesi
LICENSING EVALUATOR NAME:Fabian Schwartz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 09/26/2024 03:55 PM - It Cannot Be Edited


Created By: Fabian Schwartz On 09/26/2024 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FAIZI, PALWASHA & FAIZI, SAMIULLAH
FACILITY NUMBER: 343624549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensees did not comply with the section cited above by not conducting fire drills or maintaining a fire drill log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2024
Plan of Correction
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Licensees will conduct a fire drill and document it in supplied fire drill log and email LPA evidence of documented frie drill by 26 October 24.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Amanda Blesi
LICENSING EVALUATOR NAME:Fabian Schwartz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


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Page: 5 of 7
Document Has Been Signed on 09/26/2024 03:55 PM - It Cannot Be Edited


Created By: Fabian Schwartz On 09/26/2024 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FAIZI, PALWASHA & FAIZI, SAMIULLAH
FACILITY NUMBER: 343624549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(6)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (6) Outdoor play areas shall be either fenced, or outdoor play areas shall be supervised by the licensee Section 102417(g)(5).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensees did not comply with the section cited above by having a broken backyard fence which contains a gap large enough for a child to fit through which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2024
Plan of Correction
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Licensees will have broken fence board repaired by 26 October 24 so that fence no longer contains large hole on North side of backyard.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensees did not comply with the section cited above by not maintaining current CPR certification for Licensee Palwasha Faizi which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2024
Plan of Correction
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Licensee Palwasha Faizi will attend an in person CPR certification course and email completed certificate to LPA Schwartz by 26 October 24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Amanda Blesi
LICENSING EVALUATOR NAME:Fabian Schwartz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/26/2024 03:55 PM - It Cannot Be Edited


Created By: Fabian Schwartz On 09/26/2024 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FAIZI, PALWASHA & FAIZI, SAMIULLAH
FACILITY NUMBER: 343624549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensees did not comply with the section cited above in by having no files for 4 out of 12 children enrolled which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2024
Plan of Correction
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Licensees shall have parents of 4 children complete required licensing paperwork and email completed forms to LPA Schwartz by 26 October 24.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensees did not comply with the section cited above by not maintaining infant sleep logs at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2024
Plan of Correction
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Licensees will start documenting 15 minute checks on napping infants and email completed logs to LPA Schwartz by 26 October 24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Amanda Blesi
LICENSING EVALUATOR NAME:Fabian Schwartz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


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