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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629428
Report Date: 09/26/2022
Date Signed: 09/26/2022 06:27:53 PM

Document Has Been Signed on 09/26/2022 06:27 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:LUMUMBA, SHAMI FAMILY CHILD CAREFACILITY NUMBER:
376629428
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/26/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Shami LumumbaTIME COMPLETED:
06:30 PM
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On 09/26/22 at 4:40PM, LPA, Luigi Gargaro, conducted an announced prelicensing inspection for a relocation with the applicant to ensure compliance with standards established in CCR, Title 22, Division 12, Chapter 3, for Family Child Care Homes. Analyst met with the applicant Shami Lumumba. The one floor home was toured and inspected to ensure an environment safe for the care and supervision of children. The fire extinguisher and smoke and carbon monoxide detector meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. The applicant was asked whether she had any bodies of water or weapons in the home and she replied no. CPR and First Aid certifications expired on 09/05/22. 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. Applicant owns the home and submitted proof of control of property in the form of a home escrow statement with her original application.

Applicant will be using the following rooms for childcare: the living room, the kitchen, the first bedroom located behind the kitchen (listed as "room 1" in the facility sketch) and the bathroom located in that first bedroom. The kitchen has an installed safety gate at its entrance but as it is used as a pass through area to get to the for use bedroom, it will be considered a "for use" area in which child proofing requirements will aways need to be maintained. Applicant can keep the gate closed at her discretion if she is cooking or needs to keep it that way for a temporary activity. Analyst inspected the kitchen today and found it to be safely child proofed. The for use bedroom has a wall heating unit that applicant attests will not be used during day care and understands that if she does decide to operate it will install a safety gate around it or other security device to make it inaccessible to day care children.

Off limits are the other three bedrooms and the second home bathroom. They are made off limits with an entrance door off the living room that has a door knob cover on it that leads to that separate, self-contained portion of the home. The applicant has sufficient day care equipment available.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Luigi Gargaro
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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: LUMUMBA, SHAMI FAMILY CHILD CARE
FACILITY NUMBER: 376629428
VISIT DATE: 09/26/2022
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Applicant has a fenced backyard that will not be used for the day care as it stores her personal items. The backyard is made off limits with two latching and locking side gates and contains an off limits locked storage shed. The only other entrances to the backyard are through a sliding patio door from the for use bedroom and a kitchen exit door. The bedroom exit is made off limits with a locking gate with a door knob cover on its handle while the kitchen door also has an installed door knob cover as well as a turn lock. Applicant will be instead using her gated front yard for outdoor activity.

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. LPA and applicant discussed California Megan's Law and he provided applicant with the website address: www.meganslaw.ca.gov for her to review information regarding her facility on a regular basis.

Applicant was reminded of requirements for children’s records, child abuse and unusual incident reporting, immunizations, adults living or working in the home and associated civil penalties, shaken baby syndrome, and SIDS. Applicant was reminded that corporal punishment, smoking, walkers, exersaucers, bouncy seats and jumpers are not allowed in day care.

No corrections are required, however, a provisional license for 8 will be issued today at this new location as applicant's CPR/First Aid certifications expired on 09/05/22. Applicant has 90 days, to 12/26/22, within which to obtain new EMSA approved certifications and submit them to analyst. When received, license will be changed from a provisional one to a regular status one.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Luigi Gargaro
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC809 (FAS) - (06/04)
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