435700351-4-7-2023-52-CC-CURE-CQNRKM-20230407130547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435700351
Report Date: 04/07/2023
Date Signed: 04/07/2023 01:06:26 PM

Document Has Been Signed on 04/07/2023 01:06 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	GHRAIRI, HALLOUMA		FACILITY NUMBER:	435700351
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	04/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Hallouma Ghrairi		TIME COMPLETED:	01:30 PM

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On 04/07/2023 at 9:30am Licensing Program Analyst (LPA) Christina Uribe, met with licensee Hallouma Ghrairi for an UNANNOUNCED ANNUAL INSPECTION. No other individuals were present at the time of the inspection. Upon arrival LPA provided licensee a copy of the Entrance Checklist (LIC 126). The home was toured to conduct a Health and Safety Inspection. The facility currently plans on operating Monday-Friday 8:00am-5:30pm.

The licensee does not currently operate her Family Child Care Home as she does not have any clients and is working with her local Resource & Referral Agency to build a clientele. While actively working to gain enrollment, the licensee is currently working outside of the home. Until then the licensee will remain on active status with her license.

The home is a two story home with 2 bedrooms, 2 bathrooms, living room, and kitchen. LPA observed the home to be neat and clean with central heating and ventilation for safety and comfort. All on/off-limit areas are consistent with the facility's pre-licensing reports. The home is located in the Verve Apartment Complex.

The OFF-LIMIT AREAS are the upstairs bedroom and upstairs bathroom and are inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS are the kitchen, living room, downstairs bathroom, & downstairs bedroom.

The facility's apartment complex does have a communal outdoor pool and game room for children located on the premises, however, the licensee will not be utilizing either of these spaces at any time for her day care. All outdoor activities will take place on the licensee's porch or a nearby park within walking distance. Licensee understands her responsibility for 100% supervision during these times outside of the home.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GHRAIRI, HALLOUMA	FACILITY NUMBER: 435700351
	VISIT DATE: 04/07/2023

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All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, carbon monoxide detector, telephone and fully stocked first aid kit. Per licensee, there are no firearms on the premises or pets in the home.

The licensee completed the Health and Safety training, CPR/First Aid certification has expired and the licensee has provided proof to LPA Uribe that she will be renewing this certification on 04/14/2023. Licensee will email LPA Uribe a copy of the new Pediatric CPR/First Aid certificate. The licensee will also email LPA Uribe a copy of the completed renewal of the Mandated Reporter Certificate. The licensee is in compliance with the immunization laws.

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 communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email notifications.

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.

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.

Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GHRAIRI, HALLOUMA	FACILITY NUMBER: 435700351
	VISIT DATE: 04/07/2023

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Licensee asked LPA Uribe about what is needed in order to have an assistant employed. Please see list below for documents needed:

Immunization Record - Measles (MMR), Pertussis (Tdap), & Influenza (optional)
Proof of TB Clearance
Mandated Reporter Certificate for Child Care Providers (AB 1207)
Employee's Rights (LIC 9052) Form
Statement Acknowledging Requirement to Report Child Abuse (LIC 9108) Form
Pediatric CPR/First Aid Certificate (If assistant will ever be left alone with children)
Criminal Record Clearance

Licensee will send LPA Uribe a copy of these documents once she has obtained an assistant.

Licensee also stated that during her pre-licensing inspection, it was performed virtually. LPA Uribe took the time to review several documents with the licensee that was included in the Packet of Records to be Maintained which she received as an applicant one year ago. LPA Uribe discussed the forms in detail, offered resources and advisement on how the licensee can create her own Admission Agreement and why it is so important. LPA Uribe also gave licensee a printed checklist that can be used for each child's file. LPA Uribe discussed the liability insurance and the affidavit form needed if she does not plan on having it, however, licensee stated that she will obtain liability insurance.

No deficiencies nor advisories found during today's inspection.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Hallouma Ghrairi.

Page 3 of 3 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC809 (FAS) - (06/04)

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