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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434414604
Report Date: 09/03/2021
Date Signed: 09/08/2021 08:18:27 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2021 and conducted by Evaluator Anna Morales
COMPLAINT CONTROL NUMBER: 07-CC-20210714131009
FACILITY NAME:MOHAMMED, FETHYAFACILITY NUMBER:
434414604
ADMINISTRATOR:MOHAMMED, FETHYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 241-3263
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:14CENSUS: 7DATE:
09/03/2021
UNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:Fethya MohammedTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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1. Provider slapped the daycare child.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Morales conducted a Subsequent visit to deliver the finding for the above allegation. LPA was greeted by Licensee Fethya Mohammed, and one staff. Present were two infant children ( under two years old), four toddlers and one school aged child.
Complainant alleges that Provider slapped the day care child. LPA obtained information from the interviews that were conducted with the Licensee, parents, and other parties involved. LPA, also, reviewed supporting documentation, which included the Facility Roster and police report. it is concluded that the Provider slapped the day care child. The preponderance of evidence standard has been met and the allegation noted on this complaint is found to be SUBSTANTIATED.

Page 1
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20210714131009
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MOHAMMED, FETHYA
FACILITY NUMBER: 434414604
VISIT DATE: 09/03/2021
NARRATIVE
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California Code of Regulations, (Title 22, Division 12 & Chapter 1 number), are being cited on the attached LIC 9099-D. A notice of site visit was issued and posted near the facility entrance along with the Type "A" deficiency and must remain posted for 30 consecutive days. Licensee must provide copies of this report along with Type "A" deficiency to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months.

Appeal Rights Given
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 07-CC-20210714131009
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MOHAMMED, FETHYA
FACILITY NUMBER: 434414604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/07/2021
Section Cited
CCR
102423(a)(4)
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 PERSONAL RIGHTS: (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: 4)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning.
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Licensee stated that she will submit a written plan to ensure that the children's personal rights are not violated by the POC date.
AB633 Parent Notification is required.
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This requirement was not met as evidence by: Licensee/provider slapped day care children sometime in 2019 to 2021 at least on three occasions when they did not display appropriate behavior This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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AB633 Parent Notification is required. This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
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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.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3