364845620-6-20-2023-09-CC-DBRL-CSYVDS-20230620162114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364845620
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:21:21 PM

Document Has Been Signed on 06/20/2023 04:21 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	MEMON FAMILY CHILD CARE		FACILITY NUMBER:	364845620
ADMINISTRATOR:	MEMON,FARZANA&MEMON,UMER		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(213) 364-7115
CITY:	UPLAND	STATE: CA	ZIP CODE:	91784
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 5	DATE:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:			TIME COMPLETED:	04:30 PM

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On date and time listed, Licensing Program Analyst (LPA) Diana Brasel arrived at the facility to conduct an 1 year annual inspection as part of a compliance review. Upon arrival LPA placed a t/c to the facility per request on door for napping hours. LPA provided name and reason for visit and advised they would open the door. LPA was greeted by the licensee's adult daughter and granted access. There were 5 children sleeping upon arrival. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Monday - Friday 7:00 am - 6:00 pm.

OFF-LIMIT AREAS INCLUDE: Entire upstairs, laundry room, and garage.

The facility is operating within the licensed capacity and appropriate ratios

· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested during
this inspection.
· Fireplace is properly screened to prevent access by children
· All hazardous items are inaccessible to children
· Toxins are locked
· There are no weapons per licensee Farzana Memon.
· There is a gate in place at the bottom of the stairs.
· Verification of control of property on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training was completed and expires on 04/09/2025 for the licensee/co-licensee. The General training has been complete. The exam and completed certificate needs to be submitted.
· Pediatric CPR and First Aid Card expires for licensee/co-licensee on 04/19/2025.
· Health & Safety Certificate - completed on 01/20/2019

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Diana Brasel
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MEMON FAMILY CHILD CARE	FACILITY NUMBER: 364845620
	VISIT DATE: 06/20/2023

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No bodies of water on this date. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age-appropriate toys are present
· Current roster on file
· Documentation of fire and disaster drills on file – Last fire drill conducted on 06/05/2023.
· Children’s records are complete
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· Resident and/or staff records reviewed on 06/20/2023 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

- 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 provided a printed copy of the Safe Sleep regulations. Currently on children under age 2 enrolled.

- 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.

Not providing IMS- 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: http://www.ada.gov/childqanda.htm

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Diana Brasel
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MEMON FAMILY CHILD CARE	FACILITY NUMBER: 364845620
	VISIT DATE: 06/20/2023

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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.

- 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 communication platform. To receive important licensed related information to licensed facilities, 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 Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.

See LIC 809D for citation during this inspection.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and to the best of their knowledge using the facility address for their mailing address.

Exit interview conducted, appeal rights provided, and report was reviewed with the licensee Farzana Memon.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Diana Brasel
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2023 04:21 PM - It Cannot Be Edited

Created By: Diana Brasel On 06/20/2023 at 03:53 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MEMON FAMILY CHILD CARE	FACILITY NUMBER: 364845620
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(d)

Operation of A Family Child Care Home

(d) The home shall provide safe toys, play equipment and materials. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation the outdoor large wooden play structure with areas that the paint is chipping, the licensee did not comply with the section cited above due to the fact the play structure needs to be maintained, which poses a potential health, safety or personal rights risk to persons in care. LPA did observe the structure to be secure.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	The licensee stated, they will attempt to sand and repaint the areas needed this upcoming weekend, if unable it will be completed by 06/30/2023. The licensee stated, the children will not use until the structure has been repaired. The licensee stated, pictures of the completed work will be provided by email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Gilbert Sena

LICENSING EVALUATOR NAME:

Diana Brasel

LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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