<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624584
Report Date: 12/13/2022
Date Signed: 12/14/2022 08:00:49 AM

Document Has Been Signed on 12/14/2022 08:00 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:HAIDARY, SUMAYAHFACILITY NUMBER:
343624584
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
12/13/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sumayah & Maqsood HaidaryTIME COMPLETED:
04:00 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) Gagandeep Singh met with applicant, Sumayah Haidary, and her husband, Maqsood Haidary, for a pre-licensing inspection at the facility. Applicant lives in two story house. All the adults living in the house has criminal background clearance on file. The applicant owns the house and proof ownership has been submitted. Hours of operation will be seven days a week between 9:00 AM to 5:00 PM. Child care will be provided in areas: On ground floor - Living room, Kitchen, Dining area and Bathroom next to kitchen and back yard. Off limit areas: Entire second floor and Garage. All off limits areas must remain inaccessible to children. Isolation of an ill child will be in dining area next to the kitchen. Applicant was notified that prior to use of any off limits area, the department must be notified.

LPA inspected the entire home with the applicant for health and safety hazards. During the inspection, applicant’s husband provided the translation to the applicant. Applicant’s primary language is Farsi. LPA observed the house has proper temperature and ventilation. All the toxic or dangerous materials are stored in off limit areas. Stairs are barricaded. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector. There is first aid kit available. There is a variety of age appropriate toys available. As per the applicant, there are no firearms or weapons in the home. All unused electrical outlets are properly covered. Discipline policy will be to talk to the child, redirection and spending time one on one.

Applicant is informed that all adults, 18 years and older living in the home, helper or assistant must have criminal record clearance and must be associated to the facility by submitting an LIC 9182 with copy of CA DL or CA ID prior to having any contact with children in care. Failure to do so could result in an immediate civil penalty of $100.00 each day.

See next page for continuation ..............
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: HAIDARY, SUMAYAH
FACILITY NUMBER: 343624584
VISIT DATE: 12/13/2022
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
26
27
28
29
30
31
32
Continuation from previous page ..........

LPA discuss licensing regulations and capacity requirements and a capacity worksheet was provided. Licensing forms and posting requirements were reviewed with the applicant. Applicant has submitted record of CPR training valid until October 06, 2024. Applicant understands that fire/earthquake drills are to be conducted every 6 months and recorded. Applicant understands that baby walkers, bouncers, and excersaucers are not allowed. Smoking is prohibited in family child care homes. Licensee was informed about the Provider Information Notices (PINs) on CCLD website.

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

The applicant is encouraged to frequently visit website at http://www.ccld.ca.gov/ for licensing regulations and new updates. Applicant can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

Prior to issue of licensure, the applicant must
- Submit the copy of applicant's immunization against Measles and Pertussis.
- Submit copy of the Preventive health and safety training certificate.
- Submit copy of the Mandated reporter training certificate.

Copy of this report was reviewed and provided to applicant. This report will be kept in the facility file and will be made available for public review upon request. Desk Duty is available Monday through Friday between 8 AM - 5 PM at (916) 263-5744.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2