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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416731
Report Date: 06/16/2022
Date Signed: 06/16/2022 01:05:29 PM

Document Has Been Signed on 06/16/2022 01:05 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:HAMID, YOUSUFFACILITY NUMBER:
434416731
ADMINISTRATOR:YOUSUF, HAMIDFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 655-2444
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 6DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Yousuf HamidTIME COMPLETED:
01:20 PM
NARRATIVE
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On June 16, 2022 at 8:47 AM, Licensing Program Analyst (LPA), Marilou Monico, conducted a Required - 1 Year Inspection. LPA met with Licensee, Yousuf Hamid, and explained the purpose of today's visit. Also present in the home were licensee's helper and six (6) daycare children including two (2) infants, three (3) preschool age, and one (1) school age. LPA was granted access to the home by the Licensee and toured both indoor and outdoor areas during the inspection. LPA observed all required posted materials. Days and hours of operation for the facility are Monday – Friday, 6:00 AM- 6:00 PM. There are no active waivers or exceptions for this facility. Licensee states that he is the only adult residing in the home.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA observed that licensee does not maintain a current children's roster. Fire/disaster drill was conducted on June 6, 2022. LPA observed a fully charged 2A10BC fire extinguisher, functioning smoke and carbon monoxide detectors, barricaded fireplace, and barricaded wall heater. Licensee states that he does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. 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
Continuation on next pages:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: HAMID, YOUSUF
FACILITY NUMBER: 434416731
VISIT DATE: 06/16/2022
NARRATIVE
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Indoor licensed areas of the facility were inspected by LPA today and observed to be clean, orderly, and safe for the day care children. The off limit areas inside the home: kitchen, living room, and one bedroom (licensee's bedroom). LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via sippy cups and individual water bottles. The children's bathrooms are clean, sanitary, and operable. The home has a working telephone which is (408) 655-2444.

The outdoor licensed areas of the home were inspected and observed to be fenced in. Off limit areas outside the home: two locked storage sheds. There were no bodies of water observed.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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.

Seven (7) children’s files were reviewed during todays 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, and Immunization Records. Two of the children are missing LIC 282, one child missing immunization records, and three children are missing LIC 995A.

LPA reviewed two helper's files for the following records: Criminal Record Statement, Statement Acknowledging Requirement to Report Child Abuse, Employee Rights, immunization in measles, TB test, pertussis and flu. One helper (H2) is missing immunization records in measles, pertussis, and flu. Licensee has immunization record showing immunity to measles. pertussis, and flu. Licensee's CPR/First-Aid certifications expire on June 24, 2023. Licensee's Mandated Reporter Training expires on June 27, 2023. LPA reminded Yousuf that Mandated Reporter Training must be renewed by all staff every 2 years. Mandated Reported Training can be accessed at www.mandatedreporterca.com
Continuation on next page:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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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: HAMID, YOUSUF
FACILITY NUMBER: 434416731
VISIT DATE: 06/16/2022
NARRATIVE
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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


Exit interview conducted and report was reviewed with the Licensee, Yousuf Hamid.

As a result of today's inspection, deficiencies were cited on the following pages:

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: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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Document Has Been Signed on 06/16/2022 01:05 PM - It Cannot Be Edited


Created By: Marilou Monico On 06/16/2022 at 11:23 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: HAMID, YOUSUF
FACILITY NUMBER: 434416731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(B)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee does not have documentation that the infants are checked for signs of distress, flushed skin color, increase in body temperature and restlessness. This poses a potential risk to the health, safety or personal rights risk of children in care.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee states he will submit infants sleeping log together with notes that infants are checked for signs of distress, flushed skin color, increase in body temperature and restlessness by June 30, 2022.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee's helper (H2) is missing immunization in measles, pertussis, and flu. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee states he will submit proof of immunizations for his helper (H2) by July 15, 2022.
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: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


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Document Has Been Signed on 06/16/2022 01:05 PM - It Cannot Be Edited


Created By: Marilou Monico On 06/16/2022 at 11:23 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: HAMID, YOUSUF
FACILITY NUMBER: 434416731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Four of seven children enrolled are missing Parent's Rights Receipt (LIC 995A), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee agrees to submit copies of signed Parent's Rights Receipt for the four children by June 30, 2022.
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
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Based on observation and record review, the licensee did not comply with the section cited above. Licensee does not maintain a current children's roster, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee states she will submit a copy of current children's roster by June 30, 2022.
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: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


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Document Has Been Signed on 06/16/2022 01:05 PM - It Cannot Be Edited


Created By: Marilou Monico On 06/16/2022 at 11:23 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: HAMID, YOUSUF
FACILITY NUMBER: 434416731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Two of the seven children enrolled are missing the Affidavit Regarding Liability Insurance (LIC 282), which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee states that he will submit completed and signed LIC 282 for the two children by June 30, 2022.
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
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Based on observation and record review, the licensee did not comply with the section cited above. Four infants enrolled are missing documentation that staff check on them every 15 minutes when they take a nap, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee states he will submit a sleep log showing that staff check the infants every 15 minutes by June 30, 2022.
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: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


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Document Has Been Signed on 06/16/2022 01:05 PM - It Cannot Be Edited


Created By: Marilou Monico On 06/16/2022 at 12:10 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: HAMID, YOUSUF
FACILITY NUMBER: 434416731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with section cited above. One (Child #7) of the seven children enrolled is missing immunization records, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee states he will submit proof of immunization for Child #7 by June 30, 2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


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