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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628597
Report Date: 03/21/2022
Date Signed: 03/21/2022 01:10:21 PM

Document Has Been Signed on 03/21/2022 01:10 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:ADAN, MANIRA FAMILY CHILD CAREFACILITY NUMBER:
376628597
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
03/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Manira AdanTIME COMPLETED:
12:45 PM
NARRATIVE
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On March 21, 2022 at 10:25 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted an unannounced Annual Required Inspection and met with the Licensee Manira Adan. LPA disclosed the purpose of the inspection and was granted facility entry by the Licensee. The Licensee and three (3) daycare children were present in the facility during this inspection. This facility is a one story, five bedroom, three bathroom house. Licensee accompanied LPA during this inspection. The following areas used for childcare are: living room, dining room, back family room, one bathroom and one bedroom. The off limit areas are the kitchen, remaining bedrooms, remaining bathrooms and the backyard. The kitchen cabinets have cabinet locks. The bedrooms have door locks.

The fire extinguisher and smoke detector met requirements. The carbon monoxide detector was missing because it is in the process of being replaced; the new carbon monoxide detector is expected to arrive in the daycare tomorrow (03/22/2022). Hazardous items were observed inaccessible to children during this inspection. The Licensee has available toys, play equipment and materials. Licensee states children are taken to a nearby park for outdoor activities. Licensee was reminded that continuous supervision is to be given to children whenever engaged in outdoor activities. No bodies of water were observed on the premises during the inspection. Licensee stated there are no weapons in the home.

Licensee’s First Aid and CPR certifications expire on 11/26/2023. Licensee has required immunizations. Mandated Reporter Training was completed on 03/13/2022. The last fire and disaster drills were conducted and documented on 02/07/2022.

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.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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: ADAN, MANIRA FAMILY CHILD CARE
FACILITY NUMBER: 376628597
VISIT DATE: 03/21/2022
NARRATIVE
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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.

LPA reminded Licensee of 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.

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.

Deficiencies were was observed as per California Code of Regulations, (Title 22, Division 12 & Chapter 3), and are being cited on the attached LIC 809-D.

A 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. Exit interview conducted and report was reviewed with the Licensee Manira Adan.

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: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2022 01:10 PM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 03/21/2022 at 11:48 AM
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: ADAN, MANIRA FAMILY CHILD CARE
FACILITY NUMBER: 376628597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA'S observation and Licensee's statement, the licensee did not comply with the section cited above in that there was no carbon monoxide detector in the daycare, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2022
Plan of Correction
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The Licensee stated that the carbon monoxide detector was removed by maintenance earlier this morning to be replaced with a more current detector. Licensee shall obtain a working carbon monoxide detector by 03/25/2022. Licensee will self certify operation of the carbon monoxide detector and provide the LIC 9098 form to LPA no later than 03/25/2022.
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensee's statement, there is no infant sleeping log used to document the infants' sleeping checks, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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LPA provided Licensee with examples of infant sleeping logs. Licensee agrees to develop her own infant sleeping log form and provide LPA a copy of this document no later than 04/21/2022.
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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022


LIC809 (FAS) - (06/04)
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