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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376101367
Report Date: 01/19/2023
Date Signed: 01/19/2023 10:07:35 AM

Document Has Been Signed on 01/19/2023 10:07 AM - 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:MOHAMED, MANA FAMILY CHILD CAREFACILITY NUMBER:
376101367
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
01/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mana MohamedTIME COMPLETED:
10:17 AM
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On 1/19/23 at 9:00 AM, Licensing Program Analyst (LPA) Annette Sutherland conducted a change of location pre-licensing inspection. Upon arrival, LPA was greeted by Applicant, Man Ahmed Mohamed. The 4-bedroom, 4 bath home was toured and inspected to ensure an environment safe for the care and supervision of children. Also present during inspection was Licensee’s mother Nurta Aden Hussein, daughter Illhan Abucar Nunow and son Mohamed Abucar Nunow.
Applicant has provided adequate space for the children to eat, sleep and play within the home. Areas Applicant stated she will use for childcare include the following areas: living room, dining room, kitchen, bathroom #1 and backyard. Off limit areas include: Bedrooms 1-4 and bathroom 2-4, and garage. Off limit areas have been made inaccessible with the use of doorknob covers. The facility has sufficient toys and equipment available. There is a fully charged fire extinguisher, smoke and carbon monoxide detector that meet requirements and are operational. Poisons, cleaning compounds, medications and other hazardous items are inaccessible. Adequate heating and ventilation are provided. There is a working telephone/email address. Applicant stated there are no firearms and weapons in the home. The home has a fenced backyard available for outdoor activities. No bodies of water on property.
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. Applicant rents the home and has provided proof of control of property and the Landlord Notification. First Aid and CPR expire on 11/2/24 and preventative health practice course was completed on 9/17/16 Applicant stated that she is scheduled to take lead training on 2/1/23. Applicant completed Mandated Reporter Training and expires on 1/6/24. Staff immunization requirements per SB792 were met. All required postings are posted.
Continued on LIC 809C
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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: MOHAMED, MANA FAMILY CHILD CARE
FACILITY NUMBER: 376101367
VISIT DATE: 01/19/2023
NARRATIVE
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LPA informed Applicant that all unusual incident reports shall be submitted to Licensing office via email at SDIncidentReports@dss.ca.gov or via fax at (619)767-2203. Duty officer number is (619)767-2248. 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.

Applicant was reminded of requirements for children’s records, facility roster, child abuse and unusual incident reporting, immunization's, 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 at https://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.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
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: MOHAMED, MANA FAMILY CHILD CARE
FACILITY NUMBER: 376101367
VISIT DATE: 01/19/2023
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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

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.

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.

No corrections are needed. A provisional license for 8 children may be granted upon final file review (valid for 90 days). Applicant agreed to comply with all regulations and laws governing family child-care homes. Once lead poison prevention certificate is submitted to Licensing, a regular license will be granted.

An exit interview was conducted with applicant. Applicant was provided a copy of their Appeal Rights (LIC9058) along with a copy of the report (LIC809) and their signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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