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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629082
Report Date: 03/28/2022
Date Signed: 03/28/2022 11:45:17 AM

Document Has Been Signed on 03/28/2022 11:45 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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:ELMI, FARDOUS FAMILY CHILD CAREFACILITY NUMBER:
376629082
ADMINISTRATOR:FARDOUS ELMIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 908-0823
CITY:SAN DIEGOSTATE: CAZIP CODE:
92105
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Fardous ElmiTIME COMPLETED:
10:15 AM
NARRATIVE
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On March 28th, 2022 at 8 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted an unannounced Annual Required Inspection and met with the Licensee Fardous Elmi. LPA disclosed the purpose of the inspection and was granted facility entry by the Licensee. Only the Licensee was present in the facility during this inspection. This facility is a one (1) bedroom one (1) bathroom house. Licensee accompanied LPA during this inspection. The following areas used for childcare are: living room, bathroom and kitchen. The off limit area is the bedroom, which is made inaccessible using doorknob covers.

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements. 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 has required immunizations. Mandated Reporter training was completed on 03/27/2022. There was no facility roster. The last fire and disaster drills were conducted and documented on 11/02/2021.

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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 03/28/2022 11:45 AM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 03/28/2022 at 09:00 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: ELMI, FARDOUS FAMILY CHILD CARE
FACILITY NUMBER: 376629082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a daycare record review and Licensee's statement, the licensee did not comply with the section cited above in three (3) out of three (3) children lacked an emergency information card, which poses as a potential safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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LPA provided Licensee with a blank LIC 700 "Identification & Emergency Information" form. Licensee agrees to provide LPA with the three (3) children's completed LIC 700 form no later than 04/28/2022.
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 a daycare record review and the Licensee's statement, the licensee did not comply with the section cited above in that three (3) out of three (3) children lacked an emergency information carrd, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
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LPA provided Licensee with a blank LIC 700 "Identification & Emergency Information" form. Licensee agrees to provide LPA with the three (3) children's completed LIC 700 form no later than 04/28/2022.
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: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/28/2022 11:45 AM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 03/28/2022 at 09:00 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: ELMI, FARDOUS FAMILY CHILD CARE
FACILITY NUMBER: 376629082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

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 observation and Licensee's statement, the licensee did not comply with the section cited above in there was no current child roster was in the day-care which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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LPA provided Licensee with a blank LIC 9040 Child Care Roster form. Licensee agrees to complete this form and provide to LPA no later than 04/28/2022.
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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/28/2022 11:45 AM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 03/28/2022 at 09:00 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: ELMI, FARDOUS FAMILY CHILD CARE
FACILITY NUMBER: 376629082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

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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Based on a review of the daycare files and Licensee's statements, the licensee did not comply with the section cited above in that three (3) out of three (3) children lacked a completed LIC 995A in their individual daycare files, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
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LPA provided Licensee with a blank LIC 995A "Family Child Care Notification of Parent Rights" form. The Licensee agrees to have the parent complete this form and provide LPA with a copy of this signed form no later than 04/28/2022.

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: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/28/2022 11:45 AM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 03/28/2022 at 09:00 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: ELMI, FARDOUS FAMILY CHILD CARE
FACILITY NUMBER: 376629082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a review of daycare child files and Licensee's statement, the licensee did not comply with the section cited above in that three (3) out of three (3) children did not have a signed LIC 282 forms and the Licensee stated she does not have liability insurance, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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LPA provided Licensee with a blank LIC 282 "Affidavit Regarding Liability Insurance" form. Licensee agreed to provide this completed form (signed) by the parent to LPA no later than 04/28/2022.
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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022


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: ELMI, FARDOUS FAMILY CHILD CARE
FACILITY NUMBER: 376629082
VISIT DATE: 03/28/2022
NARRATIVE
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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 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 Fardous Elmi. 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: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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