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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004488
Report Date: 11/21/2022
Date Signed: 11/21/2022 11:26:05 AM

Document Has Been Signed on 11/21/2022 11:26 AM - 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:MIR, FATEMAFACILITY NUMBER:
384004488
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Fatema MirTIME COMPLETED:
12:00 PM
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On November 21, 2022 at approximately 09:20AM, Licensing Program Analyst (LPA) Nathan Garcia arrived at the facility to conduct an unannounced Annual Inspection on this day, and met with the Licensee, Fatema Mir. Purpose of the inspection was explained. Present there was 1 child in care with the Licensee and her husband taking care of the children. Also present in the home are the Licensee's children, ages 17 and 12, sleeping. The child enrolled was napping during the inspection. Licensee was operating in compliance to the required licensed capacity and ratio limits as of today. Per Licensee, the 3 bedroom and 2 bathroom unit, located on the 5th floor of the building, unit 532. LPA verified the background check clearance of the adults working or living in the home. The hours of operation are: M-F, 8:00 AM – 5:00 PM. Licensee provides breakfast, lunch, and PM snacks after nap time.

Daycare areas: Living Room, 2 bedrooms and Bathroom. Off Limit areas: 1 Bedroom and bathroom and Kitchen. LPA and Licensee inspected the entire childcare area for Health and Safety hazards. LPA observed that off limit areas were locked and made inaccessible to the children in care. There were multiple combined carbon monoxide and smoke detectors in the home. LPA performed the tests to check the functionality of the detector. A fire extinguisher of size 1A10BC was also available in the home located in the kitchen. First Aid kit is fully stocked and accessible. Per Licensee, there are no firearms or weapons in the home. Licensee states, there are no bodies of water in the home.

LPA observed that the house is in good repair and free of hazards with proper temperature and ventilation and lighting. LPA observed that there is a variety of age-appropriate toys, books, and other learning material available in the home for the children in care. Electric outlets have been secured with child protective covers, and a working phone is on site.

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SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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: MIR, FATEMA
FACILITY NUMBER: 384004488
VISIT DATE: 11/21/2022
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All posting requirements are met and posted near the childcare entrance. Licensee has current and valid CPR and First Aid card expiring on 8/23. LPA reviewed facility records including child's files present today. LPA observed that files have records of immunization, names, addresses and telephone numbers of each child's authorized representative. The fire drills are conducted every 6 months and the most recent one was on 10/12/22 for the building and the facility conduct their own every 6 months, last on June 1, 2022. The facility does not have any children in care that requires special medications or allergies.

Licensee 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.

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.



The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensees were informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA reviewed AB 1207 with the Licensees. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. Effective July 1, 2020, Licensees must have proof of completion of EMSA certified lead poison training if applying for a change of location or capacity change to an existing license.

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SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: MIR, FATEMA
FACILITY NUMBER: 384004488
VISIT DATE: 11/21/2022
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LPA encouraged the Licensee to visit the Licensing website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

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.

LPA discussed the safe sleep regulations with licensee 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 licensee 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.

A copy of this report was given to the Licensee and a site visit notification must be 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 licensee, Fatema Mir.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC809 (FAS) - (06/04)
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