344501151-5-24-2024-53-CC-JTES-D5L2H6-20240524172415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 344501151
Report Date: 05/24/2024
Date Signed: 05/24/2024 05:24:26 PM

Document Has Been Signed on 05/24/2024 05:24 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:	SAMI, RUBINA		FACILITY NUMBER:	344501151
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 3	DATE:	05/24/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:45 PM
MET WITH:	Rubina Sami		TIME VISIT/ INSPECTION COMPLETED:	05:40 PM

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Licensing Program Analyst (LPA) Jennie Tedlos met with Applicant, Rubina Sami for the purpose of a Pre-Licensing evaluation. All individuals subject to criminal background review have obtained a criminal record clearance. Applicant's tentative hours are Monday - Friday from 6 AM to 10 PM. LPA observed 3 children in care. Children in care are the Applicant's own children.

A health and safety inspection was conducted inside and out. The home is 2 stories. The off-limits area in the home include laundry room, garage, kitchen, living room #2, Room #2, backyard, and entire upstairs. Off-limits areas will remain inaccessible to children by door knob covers, baby gates and/ or baby latches. Applicant understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Outdoor area was toured. Applicant states that the backyard will remain off limits for now. Applicant states that there is a park nearby that the facility may utilize. Applicant understands that going to the park will require 100% supervision. There are no bodies of water on the premises and Applicant states there are no weapons. LPA verified toxic and hazardous items were inaccessible to children in care. Functioning smoke and carbon monoxide detectors were observed. 2A10BC fire extinguisher and first aid kit were observed.

LPA discussed the Mandated Reporter Training with Applicant. Applicant speaks Farsi and therefore does not need to do the Mandated Reporter Training. Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/.

Current pediatric CPR and first aid training was verified and expires 01/2026.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

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: SAMI, RUBINA	FACILITY NUMBER: 344501151
	VISIT DATE: 05/24/2024

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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information. To receive important licensed related information, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The applicant provided proof of control of property.

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) or (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.

LPA discussed the safe sleep regulations with applicant 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 applicant 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.

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.

Applicant was informed of the MyChildCarePlan.org site, 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.

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SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

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

FACILITY NAME: SAMI, RUBINA	FACILITY NUMBER: 344501151
	VISIT DATE: 05/24/2024

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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. 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 LIC 624/ Unusual Incident Report shall be submitted within 7 days to remain in compliance. Applicant understands that if any structural changes are made to the FCCH; Licensing must be notified PRIOR to construction.

Applicant understands that children’s and staff’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years. LPA reviewed with Applicant the LIC 311D Forms/Records To Keep In Your Family Child Care Homes, Children’s Forms/Records, Facility Forms/Records, and Information to be Posted. APPLICANT understands that fire drills must be conducted and documented once every six months.

As of today, 05/24/2024, Rubina Sami is approved for a Small Family Child Care Home licensed to serve 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.

A notice of site visit was given to applicant and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the Applicant, Rubina Sami.

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC809 (FAS) - (06/04)

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