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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004103
Report Date: 08/12/2021
Date Signed: 08/12/2021 04:36:25 PM

Document Has Been Signed on 08/12/2021 04:36 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: 0CENSUS: 2DATE:
08/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Employee, Liza BurgosTIME COMPLETED:
03:00 PM
NARRATIVE
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On August 12, 2021 at 1:30pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, case management inspection. LPA met with Licensee's helper (H1) and explained purpose of inspection. Present in home were H1 and two minor children (preschooler and school age). Licensee is currently licensed for a small family child care home. Licensee applied for large license April 28, 2021. Prior to inspection, LPA made numerous attempts to contact licensee and did not receive a response.

H1 has a criminal record clearance on file. Hours of operation are Monday to Friday from 8:30am to 4:30pm. LPA and H1 conducted a health and safety inspection inside the home. The home consists of 3 bedrooms, 2 and a half bathrooms, living room, dining room, playroom, deck area, backyard and garage. Based on pre-licensing inspection dated 05/03/2019, the DAY CARE AREAS are the kitchen, living room, dining room, playroom, deck area, bathroom #1 and bedroom #1 (napping room). The OFF-LIMITS AREAS are the backyard, bedroom #2, bedroom #3, bathroom #2, hallway and entire downstairs (garage and part of bathroom #1).

At 1:35pm, LPA observed enrolled child using bedroom#2 and bathroom#2 (both OFF-LIMIT areas). H1 also stated children do not use deck area but use the backyard for outdoor play instead (OFF-LIMIT area). Per H1, Licensee is aware of children's use of OFF-LIMIT areas.

At 1:50pm, LPA requested to review H1's CPR and First Aid certificate. H1's CPR is current and will expire 04/23/2023.

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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 08/12/2021
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(Continued)

LPA requested to review H1's proof of required immunizations. H1 stated immunizations are up to date but could not provide proof to LPA. Per H1, she was unaware if licensee keeps H1's file in home.

After today’s inspection, an exit interview was conducted with H1. Licensee was issued a Type B citation for an enrolled child's access and use to OFF-LIMIT area without department's prior knowledge or consent. Licensee was also issued a Type B citation for not having staff records readily available in facility.

This report was reviewed and discussed with H1. A copy of report, Notice of Site Visit and appeal rights were emailed to H1 and Licensee. Licensee and H1 were reminded that a site notice shall be posted in a prominent place in facility for 30 days during the hours of operation. Failure to maintain postings as required will result in a civil penalty of $100.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2021 04:36 PM - It Cannot Be Edited


Created By: Catrina Quimbo On 08/12/2021 at 02:17 PM
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: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited
CCR
102416.3(a)(1)

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102416.3 Alterations to Existing Buildings or Grounds (a)(1) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of...Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. This requirement was not met as evidenced by:
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Licensee is to install child safety locked handle to bedroom #2 and bathroom#2. Proof of installation shall be provided to LPA no later than 09/03/2021 by 5:00pm.
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Based on observation, interview and record review, an enrolled child was using bathroom#2 and bedroom#2 (both OFF-LIMIT areas). This poses a potential health and safety hazard to children in care.
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Type B
09/03/2021
Section Cited
CCR102391(d)(1)(E)

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102391 Inspection Authority of the Department (d)(1)(E) The licensee shall permit the Department to inspect...Any other records containing current emergency or health-related information for current children in care or staff. This requirement was not met as evidenced by:
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Licensee is to provide LPA proof of H1's immunizations no later than 09/03/2021 by 5:00pm.
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Based on observation, interview, and record review, H1 did not have proof of immunization during LPA inspection. This poses a potential safety hazard to children in care.
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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:Cindy Interiano
LICENSING EVALUATOR NAME:Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021


LIC809 (FAS) - (06/04)
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