434409517-7-25-2024-07-CC-MMOO-D7HP4E-20240725105902

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409517
Report Date: 07/25/2024
Date Signed: 07/25/2024 10:59:58 AM

Document Has Been Signed on 07/25/2024 10:59 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	SHAMS, AMINA		FACILITY NUMBER:	434409517
ADMINISTRATOR/ DIRECTOR:	SHAMS, AMINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 379-5164
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95130
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	07/25/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:59 AM
MET WITH:	Amina Shams		TIME VISIT/ INSPECTION COMPLETED:	11:10 AM

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 July 25, 2024 at 8:59 AM, Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Annual Random inspection. LPA met with Licensee, Amina Shams, and explained to her the nature of today's visit. Licensee states that she does not have daycare children since August 2023. Licensee states she wanted to keep her daycare license on active status. All required posting materials were posted. The daycare is open Monday thru Friday from 8:00 AM to 6:00 PM. There are no active waivers or exceptions for this facility. The daycare is a one storey home with three (3) bedrooms and two (2) bathrooms. Per Licensee, she is the only adult residing in the home. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke and carbon monoxide detectors, barricaded fireplace, and gated kitchen. Licensee states that there are no weapons or firearms in the home. 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 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: http://www.ada.gov/childqanda.htm Licensee, Amina Shams, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated. Continuation on next pages:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHAMS, AMINA	FACILITY NUMBER: 434409517
	VISIT DATE: 07/25/2024

NARRATIVE

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Off limit areas inside the home are: two bedrooms, master bathroom, kitchen, family room, and dining area. LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 379-5164. Off limit areas outside the home: fenced off area of the backyard.

Licensee has immunizations in measles, pertussis and flu. Licensee has expired Mandated Reporter Training. Licensee has current Pediatric CPR/First Aid certifications with an expiration date of January 13, 2026. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

LPA provided and 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 reminded 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.

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.

Licensee, Amina Shams, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&R's) throughout California.

Continuation on next page:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHAMS, AMINA	FACILITY NUMBER: 434409517
	VISIT DATE: 07/25/2024

NARRATIVE

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The following forms to be sent to Licensing by 08/08/24:
1) Updated Application for a Family Child Care Home License (LIC 279)
2) Updated Emergency Disaster Plan (LIC 610A)

As a result of today's inspection, Type B deficiency was cited on the following page.

Exit interview conducted and report was reviewed with Amina Shams, Licensee.

During the exit interview, the Licensee, Amina Shams, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/25/2024 10:59 AM - It Cannot Be Edited

Created By: Marilou Monico On 07/25/2024 at 10:14 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHAMS, AMINA	FACILITY NUMBER: 434409517
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee's Mandated Reporter Training is expired which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2024
	Plan of Correction
1 2 3 4	Licensee states that she will complete the training and will submit a copy of certificate by 08/08/24.

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:

Joel Segura

LICENSING EVALUATOR NAME:

Marilou Monico

LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC809 (FAS) - (06/04)

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