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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004488
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:52:22 PM

Document Has Been Signed on 04/11/2024 02:52 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MIR, FATEMAFACILITY NUMBER:
384004488
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 0DATE:
04/11/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Fatema Mir /Md Jahidul MirTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On April 11, 2024, at 2:00pm, an informal office meeting was held at the San Bruno Regional Office. The meeting was attended by Licensing Program Manager (LPM), Garfield Leung, Licensing Program Analyst (LPA) Man Tso, and the Licensee Fatema, Mir and the licensee's spouse, Md Jahidul Mir. The purpose of the meeting was to discuss the fracture of two children in care in 6 months, while the facility did not report the incidents to the Licensing.

Discussed during the meeting were the followings:

A) The Licensing have the concerns about there were two serious injury incidents in 6 months, happened in January and July 2023. However, the licensee did not report these 2 incidents to the Licensing. The licensee should report any incidents or injuries occurring during day care hours in 24 hours by phone and submit the Unusual Incident/Inquiry Report (LIC624B) in 7 days.

B) Refer to the deficiencies citation for not reporting the incidents/injuries, the licensee is required to submit a written plan to the Licensing. LPA received the written plan sent by the licensee stated under the following situations to take the actions listed below.

Incidents or reasons of reporting:
1) Suspected child abuse ; 2) Neglect ; 3) Physical abuse
4) Exploitation; 5) Sexual abuse ; 6) Physical injury

7) Unlawful corporal punishment ; 8) Domestic violence ; 9) Parental substance use

CONTINUED>>>...PAGE 2...

Garfield Leung
Man Tso
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MIR, FATEMA
FACILITY NUMBER: 384004488
VISIT DATE: 04/11/2024
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Actions taken by the Licensee:
1) Maintain a log book for reporting any type of incident during daycare.

2) Trained on mandated reporting

3) Maintain a file for every kid including parent contacts, emergency contact, doctor contact and medical information to treat the children accordingly.

4) Report any type of incident through phone immediately to local police and sheriff's departments or child protective services (CPS) or California Department of Social Services (CDSS) or county welfare departments. After verbal reporting, the licensee submits written mandated reporting to the same sources within 48 hours time.



After the incident report is completed, the licensee makes sure whether it signed and dated by the by mandated reporter and the child's parent or guardian. Then the licensee maintains copies of all incident reports at the facility for a certain period and give a copy to the child's family.

A) LPM reviewed the requirements for infant safe sleep, documentation of napping infant’s 15-minute checks.

B) LPM reviewed the requirements for criminal record clearance that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption.

LPM also explained that the Department’s goal is to work with the Licensee to gain compliance. Future noncompliance and further citations may lead to administrative action against the license.

The licensee was provided a copy of the Unusual Incident Report Form (LIC624B).

Today’s office meeting cleared the deficiency issued during the visit on February 28, 2024.

An exit interview was conducted, and the report was reviewed and given to the Licensee, Fatema Mir.
SUPERVISOR'S NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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