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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100987
Report Date: 04/08/2022
Date Signed: 05/25/2022 03:26:16 PM

Document Has Been Signed on 05/25/2022 03:26 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:MONQAD, GULSOOM FAMILY CHILD CAREFACILITY NUMBER:
376100987
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
04/08/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Gulsoom MonqadTIME COMPLETED:
11:20 AM
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On 4/8/22 at 8:30 AM, Licensing Program Analyst (LPA) Adrian Mangina conducted an unannounced case management inspection for the purpose of a capacity increase with the licensee Gulsoom Monqad. Also present in the home at the time of inspection was licensee’s husband Atiquillah Monqad and adult son Muzzamil Monqad, one minor child and 2 daycare children. The 5 bedroom, 4 bathroom home was toured and inspected to ensure an environment safe for the care and supervision of children. The fire clearance was granted on 4/4/22. The fire extinguisher located in the kitchen, carbon monoxide detector located in hallway and smoke detector located in the kitchen meet requirements and are operational. At 8:45 AM LPA observed that the off limits kitchen pantry door was open and medications were left unlocked but out of reach of children Licensee advised to keep off limits areas off limits at all times. LPA advised Licensee to ensure that all outlets in accessible areas are covered and sharp items removed from drawers with non-working drawer latches. There are no bodies of water on the property. Licensee states that there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Licensee’s First Aid and CPR certifications expire on 10/25/2022. Licensee meets immunizations requirements and Mandated Reporter Training AB 1207 was waived due to language proficiency. At 9:05 AM LPA reviewed staff files for staff#1 and Staff #2. At 9:15 AM LPA observed that staff #1 and staff #2 have incomplete staff files S#1 and S#2 do not have TB test results, LIC9108 Statement Acknowledging Requirement to Report Child Abuse, LIC9052 Employee Rights or mandated reporter training certificates present. At 9:25 AM LPA observed that child roster is not complete as there is no physician information and no enroll dates. At 9:55 AM LPA reviewed 16 child files and observed that 16 of 16 child files are incomplete. LPA advised Licensee that all staff and child files must be complete. Licensee was advised to retain child records for three years after a childs end enrollment at facility.


(continued on LIC809 page 2)
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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 5
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: MONQAD, GULSOOM FAMILY CHILD CARE
FACILITY NUMBER: 376100987
VISIT DATE: 04/08/2022
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LIC809 page 2)

Licensee has provided adequate space for the children to eat, sleep and play within the home. Licensee will be using the following rooms for childcare: kitchen, living room, dining room, room #1 and hallway bathroom. The following areas will be off limits: garage, entire second floor, and back yard, which are inaccessible
through the use of safety gates. The applicant has sufficient toys and equipment available. Licensee utilizes neighborhood park for outdoor activities. Visual supervision is required at all times when children are outside.

The following information was reviewed with the Licensee information on reporting requirements for reproting suspected child abuse and unusual incidents, children’s records, immunizations, adults living or working in the home and related civil penalties, shaken baby syndrome, Safe Sleep Regulation/SIDS, and Lead Exposure. Licensee was reminded that corporal punishment, smoking, walkers, exersaucers, bouncy seats and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.


The following information was reviewed with the Licensee: information on reporting requirements for suspected child abuse and unusual incidents, children’s records, immunizations, adults living or working in the home and related civil penalties, shaken baby syndrome, Safe Sleep Regulation/SIDS, and Lead Exposure. Licensee was reminded that corporal punishment, smoking, walkers, exersaucers, bouncy seats and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA discussed and provided licensee with the following: Child Care Advocates - email address childcareadvocatesprogram@dss.ca.gov and phone number (916) 654-1541.In addition, for common questions or questions regarding licensing requirements to contact the Child Care Licensing duty line at 619-767-2248.


(Continued on LIC809 page 3)
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: MONQAD, GULSOOM FAMILY CHILD CARE
FACILITY NUMBER: 376100987
VISIT DATE: 04/08/2022
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(LIC809 page 3)

Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

See LIC809-D for deficiencies cited today. After a final file review a license for up to 14 children may be issued.

Exit interview conducted and report was reviewed and provided to the licensee Gulsoom Monqad. Licensee's signature acknowledges receipt. A Notice of Site Visit (LIC9213) was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/25/2022 03:26 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 04/08/2022 at 10:10 AM
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: MONQAD, GULSOOM FAMILY CHILD CARE
FACILITY NUMBER: 376100987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited
CCR
102421(a)

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CHILD RECORDS: The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement was not met as evidenced by:
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Licensee states will provide LPA with completed child files no later than close of business 5/6/22.
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Based of record review 16 of 16 child files are incomplete and are missing dates and signatures on forms and immunization records which poses a potential health safety and personal rights risk to persons in care.
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Type B
05/06/2022
Section Cited
CCR102416.1(a)(10)

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PERSONNEL RECORDS: Personnel records shall be maintained on each employee and shall contain...A signed and dated copy of the Notice of Employee Rights LIC 9052

This requirement was not met as evidenced by:
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Licensee states will provide LPA with completed staff files for staff #1 and staff #2 files no later than close of business 5/6/22.
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Based on file review Staff #1 and #2 did not have LIC9052, LIC9103 signed and no Mandated reporter training certificate was in file which poses a potential health, safety and personal rights risk to children in care.
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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:Renesha Pack
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/25/2022 03:26 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 04/08/2022 at 10:24 AM
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: MONQAD, GULSOOM FAMILY CHILD CARE
FACILITY NUMBER: 376100987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited
CCR
102417(g)(8)

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OPERATION OF A FAMILY CHILD CARE HOME: Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841...The roster shall include...the name and telephone number of the child's physician

This requirement was not met as evidenced by:
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Licensee states will provide completed child roster with physician information and enrollment dates for all children in care no later than close of business 5/6/22.
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Based on file review Child roster is missing physician information and enrollment dates for 16 of 16 children in care which poses a potential health, safety and personal rights risk to persons in care.
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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:Renesha Pack
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022


LIC809 (FAS) - (06/04)
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