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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100533
Report Date: 11/15/2023
Date Signed: 11/15/2023 04:48:15 PM

Document Has Been Signed on 11/15/2023 04:48 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:HASSAN, ASHA FAMILY CHILD CAREFACILITY NUMBER:
376100533
ADMINISTRATOR:ASHA HASSANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 382-7548
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY: 14TOTAL ENROLLED CHILDREN: 19CENSUS: 0DATE:
11/15/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Asha HassanTIME COMPLETED:
05:05 PM
NARRATIVE
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On November 15, 2023 at 1:30 p.m. Licensing Program Analyst (LPA), Leilani Curtis conducted an unannounced Annual Inspection and met with Licensee, Asha Hassan. LPA provided the LIC 126, Entrance Checklist to Licensee. There were no daycare children in care. Facility was observed operating within ratio and capacity. LPA conducted a tour of the home inside and outside per facility sketch. Licensee is using the following areas for daycare: living room, dining area, kitchen, bedroom #1, bathroom next to bedroom #1 and rear yard. Off-limits areas include: bedroom #2, bedroom #3 and bathroom #2 (located within bedroom #3).

Licensee has provided adequate space for the children to eat, sleep and play within the home. Home is clean, orderly and has adequate ventilation. Children’s toys and play equipment are available and observed free of hazards. There are no stairs in the home. There is a working telephone/email address. All cleaning compounds, detergents, medications, and poisons are made inaccessible through latches, locks, and/or placed up on high surfaces. There is no fireplace. The fire extinguisher and smoke and carbon monoxide detector are operational. Licensee states there are NO firearms or other weapons in the home. The outdoor play area is fenced and free of hazardous items. There are no existing bodies of water present. Children records were reviewed for Emergency Information. The last documented disaster/fire drill occurred on 1/24/23. The licensee does not maintain a current children’s roster. LPA reviewed six children’s files. All six files were missing signed emergency information forms (LIC700), notification of parents rights ( LIC995A) and Insurance Affidavits, (LIC282). Two children’s files were also missing signed consent for emergency medical treatment forms (LIC627). There are no new adults living or working in the home over the age of 18 years. All adult residents and helpers have submitted for criminal record and child abuse index clearances or exemptions.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 11/15/2023 04:48 PM - It Cannot Be Edited


Created By: Grace Curtis On 11/15/2023 at 03:00 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: HASSAN, ASHA FAMILY CHILD CARE
FACILITY NUMBER: 376100533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The licensee has not conducted or documented a disaster/fire drill within the last 6 six months. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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The licensee states that she will conduct and document a disaster/fire drill and she will send LPA a copy of the documentation via email by 11/27/23.

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:Tashima Daniel
LICENSING EVALUATOR NAME:Grace Curtis
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 11/15/2023 04:48 PM - It Cannot Be Edited


Created By: Grace Curtis On 11/15/2023 at 03:00 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: HASSAN, ASHA FAMILY CHILD CARE
FACILITY NUMBER: 376100533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 6 out of 6 children's files reviewed do not contain signed emergency information cards (LIC700). Two files do not contain consent for emergency medical treatment. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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The licensee states that she will submit signed and fully completed emergency information cards (LIC700) for C1-C6 and signed consent for emergency medical treatment forms (LIC627) for C5 and C6.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and licensee statement, the licensee did not comply with the section cited above. The licensee does not maintain a current roster of the children in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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The licensee states that she will sent LPA a current children's roster via email by 11/27/23.
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:Tashima Daniel
LICENSING EVALUATOR NAME:Grace Curtis
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/15/2023 04:48 PM - It Cannot Be Edited


Created By: Grace Curtis On 11/15/2023 at 03:00 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: HASSAN, ASHA FAMILY CHILD CARE
FACILITY NUMBER: 376100533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 6 out of 6 files reviewed do not contain signed Notification of Parent's Rights forms (LIC995A). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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The licensee states that she will submit signed Notification of Parent's Rights forms for C1-C6 to LPA via email by 11/27/23.

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:Tashima Daniel
LICENSING EVALUATOR NAME:Grace Curtis
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/15/2023 04:48 PM - It Cannot Be Edited


Created By: Grace Curtis On 11/15/2023 at 03:00 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: HASSAN, ASHA FAMILY CHILD CARE
FACILITY NUMBER: 376100533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 6 out of 6 files reviewed do not contain signed insurance affidavits (LIC282). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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This licensee states that she will submit signed insurance affidavits, LIC282, for C1-C6 to LPA via email by 11/27/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tashima Daniel
LICENSING EVALUATOR NAME:Grace Curtis
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: HASSAN, ASHA FAMILY CHILD CARE
FACILITY NUMBER: 376100533
VISIT DATE: 11/15/2023
NARRATIVE
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The licensee’s uncle Ibrahim Hussein is associated to the facility but has not been cleared. His status is pending. The licensee states that her uncle lives in Orange County California and is not in the home when the children are present. LPA advised Licensee to have her uncle resubmit his fingerprints for a criminal record clearance and that he should not visit or be present in the home when children are present until the clearance has been obtained. Pediatric CPR and First-Aid certificates are valid through January 2025. Licensee has completed the Mandated Child Abuse Reporting-per AB1207. LPA reviewed certification and it is in compliance. Immunization records per SB792 were reviewed and are in compliance.

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 reviewed the following with Licensee: Recently Approved Safe Sleep Regulations PIN 20-24-CCP dated 9/15/20, clearances and emergency drills. Licensee is reminded that corporal punishment, smoking, walkers, exersaucers, jumpers and bouncy seats shall never be permitted during daycare operation. Licensee is aware that interference with a child’s daily functions, corporal punishment, physical and mental abuse is not allowed. Licensee is reminded to make anything that reads, "Keep Out of Reach of Children" inaccessible to children.

See LIC809D for cited deficiencies.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: HASSAN, ASHA FAMILY CHILD CARE
FACILITY NUMBER: 376100533
VISIT DATE: 11/15/2023
NARRATIVE
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Child Care Providers can now sign up for Quarterly Updates and PINS through the DSS website. Please go to www.ccld.ca.gov and click on Child Care, go under Quick Links and Quarterly Updates, click on “Receive Important Updates” then enter your email address and choose which program(s) you would like to subscribe to and click “subscribe”. Duty Officer: (619) 767- 2248, Monday thru Friday 8am-5pm.

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.

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.

Exit interview conducted and report was reviewed with the licensee. This report was translated into Somali by interpreter ID#16802, Jamal.

During the exit interview Licensee Hassan confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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