384004103-5-6-2022-05-CC-CQUO-CE6QQT-20220506122250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004103
Report Date: 05/06/2022
Date Signed: 05/06/2022 12:23:51 PM

Document Has Been Signed on 05/06/2022 12:23 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 SAMI		FACILITY NUMBER:	384004103
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 7	CENSUS: 5	DATE:	05/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Substitute, Lise Lebouf		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On May 6, 2022 at approximately 9:20am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee's substitute (S1) and explained the purpose of the inspection. Licensee was not present during LPA's inspection. Per licensee's substitute, licensee was at a medical appointment. S1 has a criminal record clearance on file. LPA advised S1 to contact licensee to alert of LPA's presence in the home and purpose of the inspection. S1 stated they will text licensee. At time of inspection, present in the home were S1 and 5 enrolled children (2 infants and 3 preschool age). Facility is operating within capacity requirements and ratio on this date. Hours of operation are Monday to Friday from 8:30am to 5:00pm. Licensee rents the home which is a multi-level home that includes a kitchen, living room, dining room, play room, 3 bedrooms, 2 bathrooms, deck area, lower backyard and garage. 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. LPA inspected day care areas of home for health and safety hazards. Facility operates as a French immersion program. 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. All cleaning supplies, poisons, other chemicals and sharp objects were stored inaccessible to children on high shelves. At approximately 9:40am, LPA called licensee via cellphone to alert licensee of LPA's presence in the home and purpose of the inspection. LPA received voicemail, left a message and callback number. (Continue Report on Page 2...)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BELALIT, NAJIM SAMI	FACILITY NUMBER: 384004103
	VISIT DATE: 05/06/2022

NARRATIVE

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There was a smoke detector and carbon monoxide detector, a fully charged fire extinguisher and a working telephone on site. Per S1, there are no weapons or firearms in the home.

LPA observed napping room to be clean and in orderly condition. At approximately 10:00am, LPA observed exposed, accessible electrical outlets on walls in napping room. One electrical outlet was in use with an electrical appliance plugged in while other electrical outlet did not have anything plugged into it. LPA observed accessible electrical outlet on wall and loose electrical wiring, half taped to ground and half rolled into a wheel, located directly above a child's napping cot.

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.

LPA reviewed 7 children’s records which were complete. Children’s files have a record of emergency identification information on file as well as required immunizations. LPA reviewed S1's file. S1 has proof of required immunizations. S1 also maintains a valid CPR certificate and Mandated Reporter certificate that will expire 04/2024. Emergency drills are conducted at least once every six months and are properly logged. Last emergency disaster drill was conducted 03/15/2022.

At approximately 11:30am, S1 covered accessible, electrical outlets, re-taped loose electrical wiring, covered electric appliance with furniture and moved child's napping cot away from outlets in napping room.

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: www.ada.gov/childqanda.htm.

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.

(Continue on Page 3)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BELALIT, NAJIM SAMI	FACILITY NUMBER: 384004103
	VISIT DATE: 05/06/2022

NARRATIVE

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Facility representative 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 facility representative 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 facility representative 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.

Facility was cited Type B citation for accessible electrical outlets and accessible electrical wiring in napping room. Please refer to 809D for more information.

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 facility representative, S1.

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/06/2022 12:23 PM - It Cannot Be Edited

Created By: Catrina Quimbo On 05/06/2022 at 11:19 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BELALIT, NAJIM SAMI	FACILITY NUMBER: 384004103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in having electrical outlets and electrical wiring located above child's napping cot which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/06/2022
	Plan of Correction
1 2 3 4	S1 covered accessible, electrical outlets, re-taped loose electrical wiring, covered electric appliances with furniture and moved child's napping cot away from outlets. Deficiency cleared during LPA's inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Cindy Interiano

LICENSING EVALUATOR NAME:

Catrina Quimbo

LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC809 (FAS) - (06/04)

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