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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566215915
Report Date: 03/23/2023
Date Signed: 03/23/2023 01:56:25 PM

Document Has Been Signed on 03/23/2023 01:56 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:FAROOK FCC AKA SAFIA'S HOME DAYCAREFACILITY NUMBER:
566215915
ADMINISTRATOR:FATHIMA SAFIA FAROOKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 256-7872
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:FATHIMA SAFIA FAROOKTIME COMPLETED:
02:10 PM
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On March 23, 2023 at 11:31 AM, Licensing Program Analyst (LPA) Susana Martinez conducted an unannounced Required-1 Year annual inspection. LPA met with licensee Fathima Safia Farook and advised her of the purpose for the inspection. Together with the licensee, LPA toured the home inside and outside. At the time of inspection there were 11 children present with no other adults present.

As LPA entered the home, LPA observed a child (C1) in a play pin sleeping with two blankets inside the pin. LPA quickly approached child and observed one blanket to be covering the child's face. Licensee removed the blanket and picked up C1 from the pin. LPA reminded licensee that cribs/sleeping pins shall be free of object. LPA asked licensee for proof of 15-minute check logs, licensee states she does not keep logs. LPA provided a safe sleep sleeping chart.

The regulatory fire extinguisher located in a hallway closet was observed to be last purchased on 6/26/22. LPA reminded licensee that a regulatory fire extinguisher shall be purchased or serviced yearly. Licensee provided documentation showing the last disaster/fire drills were conducted in January 2023. Prior to touring the children's restroom, one child in care asked to use the restroom, licensee guided child to restroom and came back to the kitchen. Once the child was done using the restroom, LPA proceeded to observe the children's restroom to have an open cat litter box placed next to the toilet along with an open brown paper bag containing animal feces. LPA questioned licensee why the cat litter box was inside the bathroom, licensee states she was not aware it couldn't be in there. LPA advised it can be a hazard as children might mistake the litter box for a sand box and become contaminated. LPA asked licensee to remove the litter box immediately.

LPA reviewed five children's records. LPA did not observe an Individual Infant Sleeping Plan-LIC9227 in C1's file. LPA asked licensee if she has C1's LIC9227 form, licensee states she does not know what that is. LPA provided a copy of the form LIC9927 along with Infant Safe Sleep FAQ's.
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SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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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Document Has Been Signed on 03/23/2023 01:56 PM - It Cannot Be Edited


Created By: Susana Martinez On 03/23/2023 at 12:34 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: FAROOK FCC AKA SAFIA'S HOME DAYCARE
FACILITY NUMBER: 566215915

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2023
Plan of Correction
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LPA observed the licensee immediately remove the cat litter box from the children's restroom.
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1count child which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2023
Plan of Correction
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LPA observed licensee immediately remove the blankets from the child's face and pick up the child.
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:George Mingle
LICENSING EVALUATOR NAME:Susana Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


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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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: FAROOK FCC AKA SAFIA'S HOME DAYCARE
FACILITY NUMBER: 566215915
VISIT DATE: 03/23/2023
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LPA observed licensee's CPR/First Aid cert to be valid through 4/21/23. The license along with parent's rights poster was observed to be mounted at the entrance of the home. LPA observed licensee's mandated reporter certificate to be valid through 4/25/23.

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.

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. Licensee was reminded, infant safe sleep documentation shall be maintained in the infants file and be available to the department for review.

Licensee advised there were no children in care that required Incidental Medical Services. 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 (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

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SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: FAROOK FCC AKA SAFIA'S HOME DAYCARE
FACILITY NUMBER: 566215915
VISIT DATE: 03/23/2023
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Two type A deficiencies were cited during todays inspection. LPA Susana Martinez informed licensee Fathima Safia Farook that this report dated 3/23/2023 documents 2 Type A citations which shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.

Also, LPA Susana Martinez informed the licensee Fathima Safia Farook to provide a copy of this licensing report dated 3/23/2023 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Appeal Rights explained and provided to Licensee.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Fathima Safia Farook.

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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