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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376625411
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:39:10 PM

Document Has Been Signed on 11/29/2022 02:39 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:YUSUF, FADUMO FAMILY CHILD CAREFACILITY NUMBER:
376625411
ADMINISTRATOR:FADUMO YUSUFFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 373-3628
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Fadumo YusufTIME COMPLETED:
02:55 PM
NARRATIVE
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On 11/29/22 at 11:55 AM, Licensing Program Analyst (LPA) Keturah Lane conducted an unannounced annual inspection with the Licensee. Upon arrival, LPA met with Licensee, Fadumo Yusuf and provided the Inspection Checklist (LIC126). The one-story apartment home located on ground level was toured and inspected to ensure an environment safe for the care and supervision of children. Only Licensee was present. LPA Lane used language link to help with translation as Licensee speaks Somali and a little English. There were no children in care at time of inspection. Licensee’s son Bashir Omar arrived later to help with translation. Licensee states that she cares for two children on weekends & two other children Monday – Thursday from 2:30 – 5:30 PM. The fire extinguisher, carbon monoxide detector, and smoke detector meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. There are no bodies of water on the property. Licensee states that there are no weapons in the home. 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. Licensee was reminded that all adults 18 and over living or working in the home, 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.
Licensee’s First Aid and CPR certifications expire December 2022. Licensee meets immunization requirements and has completed Mandated Reporter Training which expires 7/7/23. Two out of four children did not have emergency records, immunizations or parents rights on file. Licensee did not have an updated roster. Required documents are posted. LPA reviewed documentation of emergency drills and last fire drill was conducted in 2019. Licensee did not have an updated fire drill log. (continued on LIC809-C...)
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: YUSUF, FADUMO FAMILY CHILD CARE
FACILITY NUMBER: 376625411
VISIT DATE: 11/29/2022
NARRATIVE
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Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for childcare include: living room, kitchen, bathroom and bedroom #3. Off limits areas include: bedroom #1 and bedroom #2 and are inaccessible through use of door knob covers. There is a working phone at the facility. The licensee has sufficient age appropriate, safe, toys and equipment available. The home has a fenced patio available for outdoor activities. Verification of control of property and landlord notification are on file. Licensee does not have landlord consent on file.

Pursuant to Title 22 of the CA Code of Regulations, the following Type B deficiencies were cited (refer to LIC 809-D).

Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov. LPA Lane reviewed Covid-19 guidelines with Licensee and provided Covid-19 resources. LPA Lane directed Licensee to website: https://www.cdss.ca.gov/inforesources/community-care-licensing to receive important updates and information.

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-and-resources/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.

(continued on LIC809-C...)

SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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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: YUSUF, FADUMO FAMILY CHILD CARE
FACILITY NUMBER: 376625411
VISIT DATE: 11/29/2022
NARRATIVE
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Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

Exit interview conducted and report was reviewed with the licensee, Fadumo Yusuf. Notice of Site Visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

To improve the quality and value of the new inspection process, a survey will 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/process.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2022 02:39 PM - It Cannot Be Edited


Created By: Keturah Lane On 11/29/2022 at 01:59 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: YUSUF, FADUMO FAMILY CHILD CARE
FACILITY NUMBER: 376625411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in and did not document fire/disaster drills every six month which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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Licensee stated she would practice a fire drill with the children and document it on the log. Licensee will send a picture of the completed log to: Keturah.Lane@dss.ca.gov by 12/12/22.

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:Monica Cuddy
LICENSING EVALUATOR NAME:Keturah Lane
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2022 02:39 PM - It Cannot Be Edited


Created By: Keturah Lane On 11/29/2022 at 01:59 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: YUSUF, FADUMO FAMILY CHILD CARE
FACILITY NUMBER: 376625411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reivew, the licensee did not comply with the section cited above in 2 out of 4 children's reocrds which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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Licensee stated she will provide proof of immunizations for C1 & C2 and send a picture via e-mail to: Keturah.Lane@dss.ca.gov by 12/12/22.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 children's records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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Licensee stated she would send LIC700 Emergency information form for C1 & C2 via e-mail to: Keturah.Lane@dss.ca.gov by 12/12/22.
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:Monica Cuddy
LICENSING EVALUATOR NAME:Keturah Lane
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/29/2022 02:39 PM - It Cannot Be Edited


Created By: Keturah Lane On 11/29/2022 at 01:59 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: YUSUF, FADUMO FAMILY CHILD CARE
FACILITY NUMBER: 376625411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in and did not have a current roster available for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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LIcensee stated she would send a copy of the completed roster via e-mail to: Keturah.Lane@dss.ca.gov by 12/12/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Monica Cuddy
LICENSING EVALUATOR NAME:Keturah Lane
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/29/2022 02:39 PM - It Cannot Be Edited


Created By: Keturah Lane On 11/29/2022 at 01:59 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: YUSUF, FADUMO FAMILY CHILD CARE
FACILITY NUMBER: 376625411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on record review the licensee did not comply with the section cited above in 2 out of 4 children's records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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2
3
4
Licensee stated she would have the parents fill out LIC995A form and provide a copy to LPA via e-mail to: Keturah.Lane@dss.ca.gov by 12/12/22.

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:Monica Cuddy
LICENSING EVALUATOR NAME:Keturah Lane
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022


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