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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376101044
Report Date: 04/26/2022
Date Signed: 04/26/2022 12:22:40 PM

Document Has Been Signed on 04/26/2022 12:22 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:POLIZA, RAWAA FAMILY CHILD CAREFACILITY NUMBER:
376101044
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/26/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Rawaa PolizaTIME COMPLETED:
12:30 PM
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On 04/26/22 at 10:10am, Licensing Program Analyst (LPA), Selina Siao conducted a pre licensing inspection with applicant. The 6 bedroom 4 bath single story house was toured and inspected to ensure an environment safe for the care and supervision of children. The home has an operating smoke and carbon detector that meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children during the inspection. The home has a swimming pool with fence that does not meet the 5 feet high requirement and there are windows from the main house and guest house/day care area that has access to the bodies of water. Applicant stated that the home doesn't have any weapon. Applicant has an EMSA approved pediatric CPR and First Aid card that are current due to expire on 2/1/2024. Applicant complete the Preventative Health Practice with Nutrition training on 02/02/2020 and the Lead Poisoning prevention course on 03/30/2022. Applicant completed the mandated child abuse training on 01/14/22. A review of the application and records on this date indicates that applicant and her two adult sons Nawar Poliza and Nicholas Poliza are the current adult residents at the home with the require TB clearances, caregiver background checks and child abuse clearances. Applicant has the required measles and pertussis immunization. Applicant has provided a copy of her rental agreement to show that she has control of the property.

Applicant will be using the following areas for childcare: guest house area including the play and sleep area, kitchen counter, dining area and bathroom. The home has a wall heater that has been sealed off and applicant does not plan on using the heater. Off limit areas includes the main house that has five bedrooms and two bathrooms, kitchen, living room and laundry room laundry room and garage. The off-limit areas have a separate entrance. Outdoor area will be the enclosed area by the day care room.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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: POLIZA, RAWAA FAMILY CHILD CARE
FACILITY NUMBER: 376101044
VISIT DATE: 04/26/2022
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Applicant was reminded of requirements for children’s records, facility roster, child abuse and unusual incident reporting, immunizations, adults living or working in the home and associated civil penalties of $100 per day, car seat law, shaken baby syndrome, and SIDS. Applicant was reminded that corporal punishment, smoking, baby walkers, exersaucers, bouncy seats and baby jumpers are not allowed in day care. The ABC’S of Safe Sleep: Sleep is Safest: Alone, on their Back in an empty Crib on a firm mattress.

Applicant shall comply with all regulations and laws governing family childcare homes and be financially secure to operate a family childcare home for children.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant 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.

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: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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: POLIZA, RAWAA FAMILY CHILD CARE
FACILITY NUMBER: 376101044
VISIT DATE: 04/26/2022
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LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted
Entrance Checklist was provided to the applicant.

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 following items needs to be corrected within 14 days and a follow up inspection is needed prior to granting a license:
  • Install a pool fence to surround the entire pool and spa that meets the departments regulation.
  • Purchase a fire extinguisher size 2A10BC or larger
  • Needs to take the in person CPR and First Aid skill course at Red Cross by 05/01/22.

Exit interview conducted and report was reviewed with the applicant.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
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