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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376624147
Report Date: 04/29/2025
Date Signed: 04/29/2025 02:49:56 PM

Document Has Been Signed on 04/29/2025 02:49 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:SHAIKH, SAMINA FAMILY CHILD CAREFACILITY NUMBER:
376624147
ADMINISTRATOR/
DIRECTOR:		SAMINA SHAIKHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(414) 364-4965
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 11DATE:
04/29/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Samina ShaikhTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 4/29/25 at 12 pm, Licensing Program Analyst (LPA) Gerald Poindexter conducted an unannounced annual inspection. Upon arrival, LPA met with Samina Shaikh. Present in the home were 11 daycare children with 1 under 24 months. Also, present was the licensee's helper and adult sister, Ghazala Shaikh. The licensee was provided with the Inspection Checklist (LIC 126). The three-bedroom, 1.5 bath, two-story home was toured and inspected to ensure an environment safe for the care and supervision of children. Licensee states hours of operation are typically Monday-Friday, 8:00 am to 6 pm.

The licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for childcare include the living room, family room, dining area and the 1/2 bath located downstairs. Off limits areas include the kitchen, garage and all of upstairs. The upstairs areas and garage are made inaccessible through use of safety gates and door locks, respectively. Licensee stated that there are no bodies of water on the premises and LPA did not observe any bodies of water. The facility has sufficient toys and equipment available.

The licensee has a fenced backyard for outdoor play area. LPA observed all areas of the backyard and the licensee stated that she understands that visual supervision is always required during outdoor activities. LPA reminded of visual supervision when escorting the children through the kitchen to the backyard.

There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector that meet requirements and are operational. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children due to safety gates and high placement. Adequate heating and ventilation are provided. There is a working telephone and email address. Licensee advised there are no firearms or ammunition stored on the premises. CONTINUED ON PAGE 2

NAME OF LICENSING PROGRAM MANAGER: Joelle Redding
NAME OF LICENSING PROGRAM ANALYST: Gerald Poindexter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: SHAIKH, SAMINA FAMILY CHILD CARE
FACILITY NUMBER: 376624147
VISIT DATE: 04/29/2025
NARRATIVE
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LPA observed all required postings were posted. Licensee maintains a current roster of the children which LPA obtained during time of inspection. Children’s records were reviewed and found to be incomplete. Staff records were reviewed. Preventative health practices course was completed. Licensee has the required immunizations per SB792. Licensee’s Pediatric CPR/First Aid is current with an expiration date of 2/1/27. Licensee’s Mandated Reporter Training Certificate expires, 2/13/27. Helper’s Mandated Reporter certificate expires 2/16/27. LPA reminded licensee that Pediatric CPR/First Aid and Mandated Reporter Training Certificates must be renewed every 2 years.

Emergency drills are conducted and documented with the last one being on 3/6/25. LPA verified that all adults living or working in the home have been fingerprint cleared and associated. LPA reminded Licensee 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. Licensee 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 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.



LPA conducted child care quality management staff interview with the licensee. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee 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: https://www.ada.gov/resources/child-care-centers/.CONTINUED ON PAGE 3
NAME OF LICENSING PROGRAM MANAGER: Joelle Redding
NAME OF LICENSING PROGRAM ANALYST: Gerald Poindexter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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: SHAIKH, SAMINA FAMILY CHILD CARE
FACILITY NUMBER: 376624147
VISIT DATE: 04/29/2025
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Licensee 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.

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 CARE tools, please send email inquiries 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.

See LIC809D for deficiencies cited



Exit interview conducted and report was reviewed with the licensee Samina Shaikh. During the exit interview, the licensee 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. Appeal Rights provided.
NAME OF LICENSING PROGRAM MANAGER: Joelle Redding
NAME OF LICENSING PROGRAM ANALYST: Gerald Poindexter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2025 02:49 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 04/29/2025 at 02:17 PM
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: SHAIKH, SAMINA FAMILY CHILD CARE
FACILITY NUMBER: 376624147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview, helper Ghazala Shaikh, was missing helper records LIC 9052, and Licensee stated she was unaware the documents were required which poses a potential health, safety or personal rights risk to children in care
POC Due Date: 05/13/2025
Plan of Correction
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Licensee stated she will submit missing helper documents to the Department by the POC due date and file the records at the facility. Email: Gerald.Poindexter@dss.ca.gov
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not possess and maintain the safe sleep logs for the only infant in care, child C1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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LPA reviewed the requirement of the Safe Sleep Log with the licensee, who stated she will begin maintaining the log immediately. Licensee will submit the sleep documentation to LPA by POC due date and keep updated in the future. Email to Gerald.Poindexter@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Joelle Redding
NAME OF LICENSING PROGRAM MANAGER:
Gerald Poindexter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
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