<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416474
Report Date: 10/24/2024
Date Signed: 10/25/2024 08:32:46 AM

Document Has Been Signed on 10/25/2024 08:32 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:MOHAMMAD, SURIYAFACILITY NUMBER:
434416474
ADMINISTRATOR/
DIRECTOR:		SURIYA MOHAMMADFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 457-4279
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 9DATE:
10/24/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Mohammad, SuriyaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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
Licensing Program Analysts (LPAs) Kate Huang and Farida Raja conducted an unannounced annual/random inspection today and met with licensee, Suriya Mohammad.

LPA observed that 9 children are present, including 1 infant. The licensee stated that there are four additional school age children who attend on a part time basis. LPAs observed that one full-time teacher is helping. The licensee stated that one part-time teacher would arrive later.

LPA checked the carbon monoxide detector, smoke detector and fire extinguisher and all are in working condition.

LPAs observed that generally the home is not clean. LPAs observed that the crib is dirty and in the crib, there are food inside, and the mattress inside the crib is not in clean condition and there are holes on the side of the crib. LPAs observed that there are spider webs in several on limit areas both outdoor and indoor. LPAs observed that the high chair is not in clean condition. LPAs observed that there are many wood materials in the bedroom which are on limit and just outside of the children's bathroom. The licensee stated that they are doing some projects now so they temporarily put the wood materials there.

The licensee stated that parents hired a driver to transport children.

LPAs asked about the infant's sleeping plan and the documentation of every 15 minutes sleep checking, but the licensee cannot provide them.

LPAs asked about the fire drills, but the licensee cannot provided the written documents. Last fire drill was conduted on 10/7/2023. LPAs reminded Licensee that fire drills need to be conducted every 6 months and documented.

LPAs checked the children's records and found that 3 children's immunization records are missing. LPA asked about the Roster of children, but it is not completed.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Linke Huang
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 6
Document Has Been Signed on 10/25/2024 08:32 AM - It Cannot Be Edited


Created By: Linke Huang On 10/24/2024 at 12:15 PM
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: MOHAMMAD, SURIYA
FACILITY NUMBER: 434416474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPAs observed that generally the home is not clean. LPA observed that the crib is dirty and in the crib, there are food inside, and the mattress inside the crib is not in clean condition. LPA observed that there are spiderwebs in several on limit areas both outdoor and indoor. LPA observed that the high chair is not in clean condition.
POC Due Date: 11/14/2024
Plan of Correction
1
2
3
4
Licensee to submit a written plan of correction.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above because the licensee cannot provide the fire drills and disaster drills documentations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
1
2
3
4
Licensee to conduct the fire drills and submit the documentation and a written plan of correction to LPA
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Linke Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/25/2024 08:32 AM - It Cannot Be Edited


Created By: Linke Huang On 10/24/2024 at 12:15 PM
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: MOHAMMAD, SURIYA
FACILITY NUMBER: 434416474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above because the licensee cannot provide S2's required MMR immunization proof, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
1
2
3
4
Licensee to submit missing immunization records and written plan of correction.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above because 3 children (C2-C4) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
1
2
3
4
Licensee to submit missing documents and plan of correction.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Linke Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/25/2024 08:32 AM - It Cannot Be Edited


Created By: Linke Huang On 10/24/2024 at 12:15 PM
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: MOHAMMAD, SURIYA
FACILITY NUMBER: 434416474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above because the licensee did not complete the roster of children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
1
2
3
4
licensee to submit completed roster and a written plan of correction to LPA
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above because the licensee cannot provide the infant sleeping plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
1
2
3
4
The licensee to provide the missing infant sleeping plan and a written plan of correction.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Linke Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/25/2024 08:32 AM - It Cannot Be Edited


Created By: Linke Huang On 10/24/2024 at 12:15 PM
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: MOHAMMAD, SURIYA
FACILITY NUMBER: 434416474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above because the licensee cannot provide the documentation of the 15-minute sleeping check for the infant which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
1
2
3
4
Licensee to submit the missing documentation of the 15-minute sleeping check and a written plan of correction.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Linke Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: MOHAMMAD, SURIYA
FACILITY NUMBER: 434416474
VISIT DATE: 10/24/2024
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
26
27
28
29
30
31
32
LPA checked the staff's records and found that one teacher (S2) missed the MMR proof.

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.

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-andresources/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.

The licensee said that she currently does not provide medicine to children. 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.

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

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

As a result of todays inspection, type B deficiencies were cited, see LIC809-D.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Suriya Mohammad.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Linke Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6