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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415491
Report Date: 07/10/2024
Date Signed: 07/10/2024 11:07:33 AM

Document Has Been Signed on 07/10/2024 11:07 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MOHAMMED, AZIZAFACILITY NUMBER:
434415491
ADMINISTRATOR/
DIRECTOR:		MOHAMMED, AZIZAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 970-9860
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
07/10/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:22 AM
MET WITH:Aziza MohammedTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Mandeep Kaur conducted an unannounced annual/random inspection. LPA met with Licensee Aziza Mohammed and explained the reason for the inspection. Present during today's inspection were Licensee, seven children and licensee's helper.

The hours of operations are Monday through Friday 7AM to 6PM. There is a board to post required postings,
such as license and notification of parent's rights.

LPA toured the inside and outside of the home with Licensee. Day care areas are: one play room, bathroom and the backyard(fenced). The off-limit areas of the home are bedroom #1, bedroom #2, bedroom #3, the bathroom between bedroom #2 and bedroom #3, and garage. LPA observed that the home is clean and orderly. Cleaning products, ,sharp objects, and other items that are dangerous to children were stored inaccessible. No body of water observed inside or outside of the home.

LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 07/10/2024. Licensee was reminded to conduct fire drill every six month.

Licensee stated that there are no weapons, such as firearm, stored in the home.

Licensee provides breakfast, morning snacks, lunch and afternoon snacks to the children. LPA discussed the Healthy Beverages requirements in Child Care.

LPA reviewed five (5) children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), and Immunization Records.

-----------------CONTINUES ON 809 DATED 02/07/2024 PAGE 2-----------------
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MOHAMMED, AZIZA
FACILITY NUMBER: 434415491
VISIT DATE: 07/10/2024
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LPA reviewed helper's file for the following records: Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), TB test, and required training. Licensee and her adult helper have immunizations in measles, pertussis and flu. Licensee has current Mandated Reporter Training certificate that was completed on January 30, 2026. Licensee has current Pediatric CPR/First Aid certification with an expiration date of October 14, 2025. 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 she registers all infant devices with the CPSC to be notified of any recalls on their purchased
equipment.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee 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&Rs) throughout California.

Continuation on next page:
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MOHAMMED, AZIZA
FACILITY NUMBER: 434415491
VISIT DATE: 07/10/2024
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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.

As a result of today's inspection, there were no deficiencies cited.

Exit interview conducted and report was reviewed with Licensee, Aziza Mohammed.

During the exit interview, the Licensee, Aziza Mohammed, 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: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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