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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376101917
Report Date: 03/13/2024
Date Signed: 03/13/2024 10:06:09 AM

Document Has Been Signed on 03/13/2024 10:06 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:SAMIULLAH, ROYA FAMILY CHILD CAREFACILITY NUMBER:
376101917
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
03/13/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Roya SamiullahTIME COMPLETED:
10:30 AM
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On March 13, 2024 at 8:45 a.m, Licensing Program Analyst (LPA), Renita Rodriguez, conducted an announced Prelicensing Inspection. LPA was greeted at the front door by applicant, Roya Samiullah, and was provided the Prelicensing Entrance Checklist. Also present in the home was Muqadasa Farooqi. LPA was granted entry after showing badge and identifying herself and disclosing the purpose of her visit. The apartment was toured and inspected for compliance. Applicant is using the following areas for daycare: Living room, kitchen, bathroom 1, and outdoor patio which are all located on the 1st floor. Bedroom 2, bedroom 3, bathroom 2 all located on the second floor will be off limits. Upstairs is off limits by security gate located at the bottom of the staircase. The children are provided a safe, healthy, and comfortable environment, furnishings, and equipment. Roya Samiullah provided proof of control of property. The rental agreement lists Zubair Farooqi, Zarghona Farooqi as tenants and Roya Samiullah as residing at the address. Applicant states that they have sufficient financial resources to sustain the license.

Applicant has a fully fenced outdoor patio for outdoor activities.

LPA tested the smoke alarm and carbon monoxide located in the living room which is operational. There is a fire extinguisher size 2A10BC in the kitchen that meets regulations. LPA did not observe, and applicant stated there are no bodies of water in the apartment complex. Applicant stated there are no weapons or ammunition stored on the premises and LPA did not observe any.

There are no fireplaces. Storage for poisons, detergents, cleaning solutions, medications are out of reach, in off limit areas, and inaccessible to children by latches and doorknob covers. There are sufficient toys and equipment available. Applicant is reminded constant supervision is required. The home is kept clean and orderly with heating and ventilation for safety and comfort. Pediatric CPR and First Aid card will expire 10/15/25. Mandated Reporter training certificate expires 2/27/26. Applicant is using cell phone to meet requirements. Required documents are posted.

SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Renita Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2024
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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: SAMIULLAH, ROYA FAMILY CHILD CARE
FACILITY NUMBER: 376101917
VISIT DATE: 03/13/2024
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

On this date, March 13, 2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

All adults listed as living in the home have received criminal background clearances. 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, 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.

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) or (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: Renesha Askew
LICENSING EVALUATOR NAME: Renita Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: SAMIULLAH, ROYA FAMILY CHILD CARE
FACILITY NUMBER: 376101917
VISIT DATE: 03/13/2024
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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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

Applicant was informed of the MyChildCarePlan.org site, 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.



LPA reviewed with Roya Samiullah the new provider packet which included 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. LPA also provided information on child abuse and unusual incident reporting. LPA provided information regarding the YMCA Resource center. Applicant was reminded that corporal punishment, smoking, walkers, exersaucers, jumpers and bouncy seats are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer.

The applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant did not obtain Property Owner/Landlord Consent form (LIC 9149). The applicant understands that, once licensed, they can operate with a maximum capacity of 6 children.

Applicant agreed to comply with all regulations and laws governing family child-care homes. Exit interview conducted and report was reviewed with the applicant Roya Samiullah.

SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Renita Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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