434416813-4-26-2023-07-CC-ALOZ-CR9PM5-20230426112546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416813
Report Date: 04/26/2023
Date Signed: 04/26/2023 11:29:05 AM

Document Has Been Signed on 04/26/2023 11:29 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	KHANALI, SHABNAM		FACILITY NUMBER:	434416813
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	04/26/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Shabnam Khanali		TIME COMPLETED:	11:45 AM

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) Ashley Lopez and Samantha Yip conducted an announced Pre-licensing inspection. LPAs met with Applicant Shabnam Khanali and explained the reason for the inspection. The purpose of this inspection is Applicant is applying for a small Family Child Care Home (FCCH). The hours of operation are 7:30AM to 5:30PM. Applicants has working cell phone at (949) 434-4405. Applicants plans on having liability insurance for the daycare. Applicant understands that the Affidavit Regarding Liability Insurance is required if she does not have day care insurance. LPAs toured the inside and outside of the home with Applicant. The off-limit areas inside the home are the kitchen, dining room, master bedroom and bathroom, and one bedroom. All disinfectant, cleaning supplies, and other items that could pose a risk to children were inaccessible to children. There are toys and equipment for children. There were no baby walkers observed during today's inspection. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. LPAs reminded Applicant that fire/disaster drills need to be conducted every six (6) months and documented. Applicant stated that there are no weapons, such as firearms, stored in the home. Applicant does have a dog. Applicant understands that smoking is not permitted. Applicant will only be using her back yard for the children, which is fenced. Applicant does not plan on transporting children and understands that children cannot be left unattended in parked vehicles. Applicant plans on providing medication. 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: http://www.ada.gov/childqanda.htm

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Ashley Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHANALI, SHABNAM	FACILITY NUMBER: 434416813
	VISIT DATE: 04/26/2023

NARRATIVE

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The form of discipline she will be using is talking to the child. LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA discussed the safe sleep regulations with Applicant 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 informed applicant 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 adults 18 and older living in the home are Applicant and her brother. Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted with Shabnam Khanali. LPA discussed with Applicant that upon review and approval of Licensing Program Manager that a license for a Small Family Child Care Home will be granted and issued.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Ashley Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

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