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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004103
Report Date: 04/11/2022
Date Signed: 04/11/2022 02:09:57 PM

Document Has Been Signed on 04/11/2022 02:09 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BELALIT, NAJIM SAMIFACILITY NUMBER:
384004103
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 6DATE:
04/11/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Substitute, Lise LeboeufTIME COMPLETED:
02:15 PM
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On April 11, 2022 at 1:00pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, case management inspection. LPA met with licensee's substitute (S1) and explained the purpose of the inspection. Per licensee's substitute, licensee is sick and is temporarily isolating at different location. All adults working in the facility have criminal record clearance on file.

LPA called licensee via cell phone, received voicemail, left a message and callback number. S1 contacted licensee as well, however, could not reach licensee via cell phone.

Present in the home were licensee's substitute and 6 enrolled children (2 infants and 4 preschool age). LPA reviewed S1's CPR certificate, Mandated Reporter certificate and required immunizations. S1 has a valid CPR and Mandated Reporter certificate that will expire 04/2024 and proof of required immunizations.

The licensee currently rents the home and is currently licensed for a small family child care home. The licensee applied for a large family child care home license on March 4, 2022.

Hours of operation are Monday to Friday from 8:30am to 5:00pm. The DAY CARE AREAS are the kitchen, living room, dining room, play room, bedroom #1 (napping room), bathroom #2, deck area and lower backyard. The OFF-LIMIT AREAS are bedroom #2, bedroom #3, bathroom #1, hallway and entire downstairs area. All off limit areas are made inaccessible to children by child safety locks.

LPA observed home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of age appropriate toys that were in good condition. Outdoor area is equipped with age appropriate toys and materials that were also in good working condition. There were no pools, spas or bodies of water on the property. All cleaning supplies, poisons, other chemicals and sharp objects were stored inaccessible to children on high shelves and/or behind child safety locked cabinets.

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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BELALIT, NAJIM SAMI
FACILITY NUMBER: 384004103
VISIT DATE: 04/11/2022
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LPA observed a fully charged fire extinguisher, smoke/carbon monoxide detectors, and working phone on site. Per licensee's substitute, there are no weapons or pets in the home. Garbage cans have tight fitting lids. The home contains a fireplace that is properly barricaded by furniture.

LPA to review capacity limits and ratios for a large family day care when licensee is present, at a later date.

Prior to granting large license, following must be completed:
-Fire clearance from SFFD
-Follow up inspection made by LPA.

After today's visit, no deficiencies were cited today.

Exit interview conducted and report was reviewed with licensee's substitute, S1.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC809 (FAS) - (06/04)
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