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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376101038
Report Date: 07/27/2023
Date Signed: 07/27/2023 05:08:33 PM

Document Has Been Signed on 07/27/2023 05:08 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:AYOOB, ANN FAMILY CHILD CAREFACILITY NUMBER:
376101038
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 12CENSUS: 7DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee, Ann Ayoob TIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA), Jennifer Lott conducted an unannounced Annual Licensing Inspection. LPA was greeted at the front door by Licensee, Ann Ayoob and granted entry after identifying herself and disclosing the purpose of her visit. The licensee is using the following areas for daycare: kitchen, dining room, living room, bedroom #3 and bathroom #1 for child care. Off limit areas include: bedroom #1, bedroom/bathroom #2, garage and all outside. The facility currently has 7 children in care of which 3 were infants. Licensee provided a copy of their current roster and is operating within the licensed ratio and capacity.

At 9:30am, LPA tested the carbon monoxide detector, smoke detector and fire extinguisher located in the kitchen/hall area. All devices were functional. There are no pools/bodies of water on the premises. There are no weapons or ammunition stored in the home. Fireplace is screened to prevent access by children. There are no stairs in the home. Storage for poisons, detergents, cleaning solutions, medications are locked and inaccessible to children. There is no outdoor play at this time as the backyard is currently under construction. The last disaster/fire drill was conducted on 07/15/23. The home is kept clean and orderly with heating and ventilation for safety and comfort. The home provides safe toys, play equipment and materials.

Children’s records contained emergency contact information and immunization records. Pediatric CPR and First Aid cards are current and will expire on 02/2024. Staff immunizations were reviewed and are in compliance. There is a working telephone and email address.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Jennifer Lott
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: AYOOB, ANN FAMILY CHILD CARE
FACILITY NUMBER: 376101038
VISIT DATE: 07/27/2023
NARRATIVE
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Safe Sleep
LPA discussed the safe sleep regulations with Licensee, Ayoob 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, Ayoob 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.

Criminal Record Clearance
Licensee, Ayoob 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 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 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.

No 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.

MyChildCarePlan.org
Licensee, Ayoob 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.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Jennifer Lott
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
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: AYOOB, ANN FAMILY CHILD CARE
FACILITY NUMBER: 376101038
VISIT DATE: 07/27/2023
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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 tools, please send them by email 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.

Based on today’s visit, deficiencies were observed and noted on the attached LIC 809D. Exit interview conducted and report was reviewed with Licensee, Ayoob.
During the exit interview, the Licensee, Ayoob 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: Jennifer Lott
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/27/2023 05:08 PM - It Cannot Be Edited


Created By: Jennifer Lott On 07/27/2023 at 11:02 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: AYOOB, ANN FAMILY CHILD CARE
FACILITY NUMBER: 376101038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onLPA's record review, the licensee did not comply with the section cited above in 3:3 intant's records reviewed did not include the 15 minute check log which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Licensee states they will complete the 15 minute check log and submit a copy to LPA via fax or email by POC date.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not comply with the section cited above in 12:12 children's records reviewed were incomplete, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Licensee states they will complete 12:12 children's files and submit an affidavit stating that the files are complete to LPA by POC date via fax or email.
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:Jennifer Lott
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023


LIC809 (FAS) - (06/04)
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