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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500204
Report Date: 07/23/2024
Date Signed: 07/23/2024 01:55:05 PM

Document Has Been Signed on 07/23/2024 01:55 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MUSTAFA, HUMAFACILITY NUMBER:
344500204
ADMINISTRATOR/
DIRECTOR:		AHMED, SHABANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 271-7575
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
07/23/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Huma MustafaTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On July 23, 2024, Licensing Program Analyst (LPA) Jennie Tedlos conducted an unannounced required annual inspection and met with Licensee, Huma Mustafa. LPA observed 3 cchildren supervised by Licensee. Criminal record clearances have been verified. Facility fees were reviewed and are current. Licensee stated there are no new residents in the home since licensure. Licensee operation hours are Monday- Friday: 7:00 AM- 6:30 PM and does not provide overnight care.

LPA and Licensee toured the facility during the inspection. Off limit areas are the Bedrooms #1, Bedroom #2, the Kitchen, the Laundry Room, and the Garage. The backyard is fenced. Licensee states that there are no weapons in the home. LPA observed that there were no hazardous items accessible to children. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector, and carbon monoxide detector meet regulation. Toys appear to be safe.

LPA conducted record reviews during the inspection. Three children and the Licensee's files were reviewed. LPA discussed mandated reporter training with the Licensee. Licensee has current Mandated Reporter Training on file. Licensee understands Mandated Reporter Training is to be completed every two years. Mandated reporter training can be accessed at www.mandatedreporterca.com. CPR/First Aid certification was reviewed for Licensee. Certification expiration date is 3/2026. LPA observed fire drills were conducted at least once every six months and documented.

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.

REPORT CONTINUED ON SUBSEQUENT PAGE, 809 C
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MUSTAFA, HUMA
FACILITY NUMBER: 344500204
VISIT DATE: 07/23/2024
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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.

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/.

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.

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.

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. Exit interview conducted and report was reviewed with the Licensee, Huma Mustafa .

No Title 22 deficiencies observed in the areas evaluated during the inspection.

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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