343625356-1-29-2024-03-CC-DVAG-CZXSWA-20240129131358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343625356
Report Date: 01/29/2024
Date Signed: 01/29/2024 01:14:03 PM

Document Has Been Signed on 01/29/2024 01:14 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:	RAHMAN, SHABANA & SHAMS		FACILITY NUMBER:	343625356
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	01/29/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Rahman, Shabana & Shams		TIME COMPLETED:	01:13 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	At 10:00 a.m. on Monday, January 29th, 2024, Licensing Program Analyst (LPA) Pa Dao Vang met with Applicants, Shabana and Shams Rahman, for the purpose of an announced, pre-licensing inspection. There were 2 of applicants' children present in the home. Applicant also speaks Pashayee, Pashto, and Dari. Facility hours of operation are from 6:00 a.m.- 9:00 p.m., Monday thru Friday. All individuals subject to criminal background review have obtained a criminal record clearance. Licensee 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. APPLICANTS OWNS THE HOME: Applicants understood that, once licensed, they can operate with a maximum capacity of 8 children in care. Applicants understands that their own children under 10 years old will count toward the childcare ratio when present during childcare hours. The one-story home consists of 4 bedrooms, 3 bathrooms, living/dining room, kitchen, backyard, front yard, laundry room, and garage. Off limit areas include: bedrooms #2, bedroom #3, bedroom #4 located in the hallway, bathroom #1, bathroom #2 in the hallway, laundry room, front yard, and garage. LPA observed functioning smoke and carbon monoxide detectors, and a working 2A-10-BC fire extinguisher. Continue report on LIC809-C...

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RAHMAN, SHABANA & SHAMS	FACILITY NUMBER: 343625356
	VISIT DATE: 01/29/2024

NARRATIVE

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There are no bodies of water. Applicant understands 100% supervision shall be maintained in or around bodies of water, and in unfenced areas. Applicant stated that there are no weapons nor poisons in the home. Cleaning compounds, knives and medications are placed on high shelves, inaccessible to children.

Applicant has completed the required CPR and First aid certification were verified and will expire 12/30/2025. Applicant is exempt from Mandated Reporter Training due to language barriers. Applicant understands that CPR/First Aid certification must be renewed every 2 years. LPA provided blank forms required for children's records including immunization card and emergency identification. LPA also provided the Parent's Rights form/poster, and reviewed vaccination requirements for children.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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. LPA observed a crib free of loose objects in the facility. LPA discussed about the infant sleep log required for each child under the ages of 1years old. Licensee must check and documenting each infant sleeping every 15 minutes.

Applicant understands that licenses are not 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 they relocate and wants to continue to provide care, they must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624B shall be submitted within seven days to remain in compliance.

Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months. Smoking prohibition and regional office relocation were discussed.
Continue report on LIC809-C...

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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: RAHMAN, SHABANA & SHAMS	FACILITY NUMBER: 343625356
	VISIT DATE: 01/29/2024

NARRATIVE

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Applicant understands to pay the annual fees of $73.00 before the due date. The annual bill will be sent through the mail with facility number, pin, and the amount of it. Applicant can pay it through the department website at https://cdss.ca.gov/inforesources/community-care/licensing-fees . They may also pay in person in our office or mailing with check/Money Order/personal check to the address listed below:

CA Department of Social Services
MS 9-3-67
P.O. Box 944243
Sacramento, CA 94244-2430

On this date, 1/29/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

This facility evaluation report was reviewed and discussed with the applicant. Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Applicant was encouraged to visit the department website at WWW.CDSS.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes.

As of today, Thursday, January 29, 2024, facility is pending for approval 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, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

Pending Item for License Approval:

1. Preventative Health and Safety Certificates (includes 1 hour of nutrition and lead prevention training for both applicants)

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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