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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409517
Report Date: 01/26/2022
Date Signed: 01/26/2022 02:02:28 PM

Document Has Been Signed on 01/26/2022 02:02 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SHAMS, AMINAFACILITY NUMBER:
434409517
ADMINISTRATOR:SHAMS, AMINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 379-5164
CITY:SAN JOSESTATE: CAZIP CODE:
95130
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
01/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Amina ShamsTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico conducted a case management inspection in response to an incident that was self-reported by Licensee to the Department on January 19, 2022 involving a daycare child. LPA met with Licensee, Amina Shams, and explained the purpose of the inspection. Also present in the home were two infants. Licensee was interviewed during the inspection.

Based on the information gathered from interviews, LPA determined that a child's personal rights were violated when she picked up licensee's hot cup of tea on the children's table which burned her upper right arm and upper chest area.

As a result of this inspection, deficiency was cited on next page.

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: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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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Document Has Been Signed on 01/26/2022 02:02 PM - It Cannot Be Edited


Created By: Marilou Monico On 01/26/2022 at 10:50 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: 01/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2022
Section Cited
CCR
101223(a)(2)

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Personal Rights - The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement was not met as evidenced by:
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Licensee states that she will submit a written plan to ensure that this incident will not occur again in the future. Licensee states that she will only drink tea in the off limit kitchen.
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A child's personal rights were violated when a child picked up a hot cup of tea on the table which burned her upper right arm and upper
chest area. This poses an immediate risk to the health, safety, and personal rights to children in care.
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Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022


LIC809 (FAS) - (06/04)
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