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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417282
Report Date: 01/09/2024
Date Signed: 01/09/2024 04:48:29 PM

Document Has Been Signed on 01/09/2024 04:48 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:SIAMER, KHALIDAFACILITY NUMBER:
434417282
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 3DATE:
01/09/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Khalida SiamerTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 3 Year inspection. LPA met with Licensee Khalida Siamer and explained the reason for the inspection. Present during today's inspection were Licensee, her two minor child, whom one was helping with the family child care home, and three (3) children, whom all were infant ages.

There is board to post required postings, such as license and notification of parents rights. The hours of operation are Monday through Friday 8:30AM to 5PM. Licensee does have liability insurance. Licensee uses her cell phone.

LPA toured the inside and outside of the home with Licensee. The off-limit areas are kitchen, master bedroom, all three bedrooms on the main level, basement, and garage. The office area is only used for meeting with parents and as a nursing room. There are stairs and a fireplace in the off limit areas. There is a gate in the hallway to make it inaccessible. There are toys and equipment for children. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was on 10/13/2023. Licensee stated that there are no weapons, such as firearms, stored in the home.

The backyard is used. The off-limit areas outside are back and right side of the backyard. LPA discussed with Licensee to ensure that anything that collects water is dumped out and that areas that are off-limit are barricaded.

----------------CONTINUES ON 809 DATED 01/09/2024 PAGE 2---------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SIAMER, KHALIDA
FACILITY NUMBER: 434417282
VISIT DATE: 01/09/2024
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--------------CONTINUATION OF 809 DATED 01/09/2024 PAGE 1---------------

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-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. LPA reviewed the sleep logs. LPA reminded Licensee to documents the times that she checks the infant.

Licensee does not transport children, but understands that children cannot be left alone and unattended in parked vehicles.

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/.

A copy of the facility roster was obtained during today's inspection. Three children's files were reviewed. The records reviewed were notification of parent's rights and immunization records.

Licensee has a valid CPR/1st Aid, which expires on 02/27/2024. Licensee completed the Mandated Reporter training on 01/12/2023. LPA discussed with Licensee that all assistant including assistants between 14 to 17 years need to complete Mandated Reporter training and have the required forms/documents.
----------------CONTINUES ON 809 DATED 01/09/2024 PAGE 3----------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SIAMER, KHALIDA
FACILITY NUMBER: 434417282
VISIT DATE: 01/09/2024
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--------------CONTINUATION OF 809 DATED 01/09/2024 PAGE 2------------

The adults 18 and over living in the home are Licensee and her spouse. Licensee also has two minor children. Licensee and her spouse has cleared criminal record, child abuse index, and TB clearance. 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.

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

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.

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.

Licensee will submit the following:
- Mandated Reporter training, TB test, and immunization records for A-1

No deficiencies were issued as a result of this inspection. Exit interview conducted and report was reviewed with Licensee Khalida Siamer. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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