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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628404
Report Date: 08/17/2021
Date Signed: 08/17/2021 01:02:55 PM

Document Has Been Signed on 08/17/2021 01:02 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:HAGUMA, L., MUGENZI, O., & SIFA, B. FCCFACILITY NUMBER:
376628404
ADMINISTRATOR:LEOCADIE, ONESPHORE, BEDIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 214-9665
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Onesphore Mugenzi, Licensee TIME COMPLETED:
01:15 PM
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On 08/17/2021, at 11:45 a.m, Licensing Program Analyst (LPA), Michelle Hood conducted an unannounced Annual Required Inspection and met with the Licensee, Onesphore Mugenzi. Licensees son translated in Kinyarwanda. Licensee Leocadie Haguma was not present at the time of inspection; however, licensee Haguma has two (2) daycare children in her care. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. Licensee accompanied LPA inside and out of the facility during this inspection. The living room, kitchen, dining room, daycare room (older children use for napping, as needed), bathroom (hallway), and backyard. The backyard has a enclosed screen canopy for the children to play. The off limits are all made inaccessible via door locks and safety locks.

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements. All hazardous items were inaccessible to children. The storage area for poisons is locked. The licensee has toys, play equipment and materials available. No bodies of water observed on the premises during the inspection. Licensee stated there are no weapons in the home. All facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Licensee’s First Aid and CPR certifications were not available. Licensee has required immunization's. Licensee is currently exempt from Mandated Reporter Training. Facility roster was not available for review. The last fire and disaster drills were conducted and documented on 06/2020. There is one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards are free from all loose articles and objects.

LPA discussed and provided Licensee with the following: child care advocates email address: childcareadvocatesprogram@dss.ca.gov. In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Michelle Hood
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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: HAGUMA, L., MUGENZI, O., & SIFA, B. FCC
FACILITY NUMBER: 376628404
VISIT DATE: 08/17/2021
NARRATIVE
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LPA provided and discussed the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances or exemptions. Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare. Licensee was also provided handouts with information regarding upcoming Safe Sleep Regulations/SIDS, Lead exposure and Shaken Baby Syndrome. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

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.

See the LIC 809D for deficiencies cited

An exit interview was conducted with the licensee. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.

LPA provided notice of site visit and observed it being posted at the facility.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Michelle Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/17/2021 01:02 PM - It Cannot Be Edited


Created By: Michelle Hood On 08/17/2021 at 12:28 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: HAGUMA, L., MUGENZI, O., & SIFA, B. FCC
FACILITY NUMBER: 376628404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2021
Section Cited
CCR
102421(b)

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Emergency Card (Child’s Record/FCCH) The licensee shall maintain, in each child’s record, a copy of the emergency information card required in section 102417(g)(7). Requirement was not met as evidenced by: Licensee was not able to provide at the time of inspection.
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Licensee will provide proof for two (2) daycare children forms no later than 09/15/2021. Licensee stated they understand all CCLD forms should be completed before children are in care.
Type B
09/15/2021
Section Cited
CCR
102417(g)(9)(A)(1)

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102417(g)(9)(A)(1)Each family child care home shall conduct fire drills and disaster drills at least once every six months. The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home. Requirement was not met as evidenced by:
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Licensee stated they will conduct a disaster drill with children in care no later than 09/15/2021. Licensees will provide LPA proof.
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LPA observed the last disaster drill was logged on 06/2020.
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Type B
09/15/2021
Section Cited
CCR
102417(g)(8)

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102417(g)(8) Roster (current)
Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. Requirement was not met as evidenced by: Licensee was not able to provide LPA a copy to review at the time of inspection.
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Licensee stated they will provide LPA a completed facility roster with children enrolled in care no later than 09/15/2021. Licensee stated he will ensure all new enrolled children are added to the facility roster.
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:Cynthia Gray
LICENSING EVALUATOR NAME:Michelle Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
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