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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624895
Report Date: 04/16/2024
Date Signed: 04/16/2024 03:21:30 PM

Document Has Been Signed on 04/16/2024 03:21 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:MOMAND, SHAHIMAFACILITY NUMBER:
343624895
ADMINISTRATOR/
DIRECTOR:		MOMAND, SHAHIMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 360-2753
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
04/16/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Shahima MomandTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kyrsten Williams and Licensing Program Manager (LPM) Seychelle De Luca conducted an unannounced annual inspection and met with the Licensee, Shahima Momand. Licensee’s spouse was also present in the home and assisted with translation. Licensee’s primary language is Pashto. All individuals subject to criminal background review have obtained a criminal record clearance. LPA observed two children in care with the licensee, which are the licensee’s own child. Licensee stated child care children arrive after school. Facility hours of operation are Monday through Friday 8:00 AM - 10:00 PM. LPA observed that the annual facility fees are current.

LPA conducted a health and safety inspection and observed that the facility is clean, safe, sanitary, and in good repair with ventilation. LPA observed the required documents were posted where visible to parents. The facility has equipment and toys safe for children. LPA observed that there were no hazardous items—such as cleaning compounds, medications, or sharp objects—accessible to children. The fire extinguisher appeared to be in working condition and accessible. LPA observed the smoke and carbon monoxide detectors are functioning. LPA observed the wall heater has a metal cover and the gate to prevent access has been removed. Licensee stated the facility no longer uses gas and the wall heater does not work. Licensee stated the home is heated electrically with the thermostat. The licensee stated there are no weapons or poisons on the premises. LPA observed the apartment complex has a pool. Licensee acknowledges 100% supervision is required around bodies of water. There are no off-limit areas in the home.

LPA did not observe a current children's roster or fire drill log. LPA reviewed children’s files and observed that all the required documentation was present in each child's file. LPA did not observe record of 15 minute sleep checks. LPA provided licensee with a printed example to document sleep checks. LPA reviewed staff and facility files and observed the required documentation. LPA observed the CPR/First Aid certificate was current and expires in February 2025. The licensee was reminded CPR/First Aid Training must be completed every two years. The licensee is exempt from taking the Mandated Reporter Training due to it not being available in her primary language.
PAGE 1. REPORT CONTINUES ON LIC809-C
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Kyrsten Williams
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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 5
Document Has Been Signed on 04/16/2024 03:21 PM - It Cannot Be Edited


Created By: Kyrsten Williams On 04/16/2024 at 02:48 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: MOMAND, SHAHIMA
FACILITY NUMBER: 343624895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in the facility does not have a current facility roster for children enrolled, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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Licensee will complete facility roster with all children enrolled and submit to LPA via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Seychelle De Luca
LICENSING EVALUATOR NAME:Kyrsten Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MOMAND, SHAHIMA
FACILITY NUMBER: 343624895
VISIT DATE: 04/16/2024
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The licensee was informed of the www.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.

The 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. 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.

LPA discussed the safe sleep regulations with the 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/.

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.
Exit interview conducted and report was reviewed with the licensee, Shahima Momand. Deficiencies are cited on the subsequent page of this report (LIC809-D) under the California Code of Regulations, Title 22. The licensee was provided a copy of their Appeal Rights (LIC9058) and the licensee's signature on this form acknowledges receipt of these rights. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Kyrsten Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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