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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344501151
Report Date: 07/23/2024
Date Signed: 07/23/2024 10:12:53 AM

Document Has Been Signed on 07/23/2024 10:12 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAMI, RUBINAFACILITY NUMBER:
344501151
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
07/23/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Rubina SamiTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
NARRATIVE
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On July 23, 2024, Licensing Program Analyst (LPA) Jennie Tedlos met with Licensee Rubina Sami for the purpose an Increase of Capacity inspection. LPA observed 0 children. Licensee stated there are no new residents in the home since licensure. All Adult residents have criminal record clearances. LPA and Licensee toured the home. The off-limits area in the home include laundry room, garage, kitchen, living room #2, Room #2, backyard, and entire upstairs. Licensee requested to put the kitchen, living room #2, and the backyard on limits during today's visit. LPA inspected the areas and cleared them to become on-limits. The new off-limit areas are the laundry room, the garage, room #2, and the upstairs. Licensee acknowledged that children may never enter these off-limit areas.

Licensee requested an increase in capacity from 8 to 14 children. Fire clearance has been approved by the Elk Grove Fire Department on 07/19/2024. The Department received the Fire Safety Inspection Clearance, and the home has been cleared for up to 14 children. Large family childcare home capacity limitations were reviewed during today's inspection.

LPA observed cleaning supplies properly stored out of reach of children. LPA observed medications out of reach of children. Licensee stated there are no weapons in the home. Fire extinguisher (2A10BC), smoke detector, and carbon monoxide meet Title 22 regulation. Toys appear to be clean and safe. The backyard is fenced. Licensee understands that prior to making alterations or additions to the home or grounds, the licensee shall notify the Department of the proposed changes.

Report Continues on 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: SAMI, RUBINA
FACILITY NUMBER: 344501151
VISIT DATE: 07/23/2024
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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, Rubina 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 [or facility representative] 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.

Report continues on to 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
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: 07/23/2024
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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.

Effective today's date, 07/23/2024, Licensee is approved for the capacity increase to serve up to either 14 children, one (1) of which must be enrolled in kindergarten and at least one (1) 6 years of age and no more than three (3) may be infants; or 12 children, four (4) of which may be infants. Infants are children under the age of 2.

Exit interview was conducted and report was reviewed with Licensee, Rubina Sami. A notice of site visit was provided and posted by LPA Tedlos and must remain posted for 30 days.

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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