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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422337
Report Date: 04/28/2022
Date Signed: 04/28/2022 01:16:23 PM

Document Has Been Signed on 04/28/2022 01:16 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SHAH, HINAFACILITY NUMBER:
013422337
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Hina ShahTIME COMPLETED:
01:30 PM
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On April 28, 2022 at approximately 8:30am Licensing Program Analyst (LPA) Russ Haderer arrived for an unannounced 1-year annual inspection. Living in the home is the licensee, her fingerprint cleared and TB tested husband. Present today is the licensee’s fingerprint and TB tested husband and 7 children in care (4 infants, 2 two-years old; 1 three-years-old). The facility is out of ratio today, this is a Type A deficiency, see LIC809D. Licensee will look into applying for a large family child care home license. The hours of operation are 9:00 to 6:00pm.

The facility is a two-story home with owned by the licensee with a living room; dining room; kitchen; family room; attached 2-car garage, side and back yard areas. The home has heating and ventilation for safety and comfort. Per the licensee, the ISOLATION AREA will be in the in the family room (day care area), away from the other children in care.

On-limit-areas include: Downstairs areas including the entry way into the childcare area and hallway to the ½ bathroom; family room (day care area); kitchen and 1/2 bathroom. Licensee was reminded that other than wipes or things used for the children in the on limits children’s bathroom, they need to be empty of most all items (or locked up) such as cleaning products etc. The kitchen has appropriate latches for safety mounted in all cupboards and drawers within the children's reach. There were no hazardous items found in any drawers or cupboards.

Off-limit-areas include: Living room, dining room, downstairs bedroom, laundry room and 2-car garage. The entire upstairs is also off limits. The downstairs off-limit areas are made inaccessible by visual supervision, a sliding pocket door from the kitchen into the dining room and a gate in the hallway blocking access to off limits areas. There are child proof door knob covers to the laundry room that also leads to the 2-car garage The off-limit areas will be inaccessible by closed and/or locked doors, child gates and/or by child supervision.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAH, HINA
FACILITY NUMBER: 013422337
VISIT DATE: 04/28/2022
NARRATIVE
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Licensee has ample age-appropriate toys and learning materials inside and outside that were observed to be safe and in good condition. Per licensee, there are no firearms in the home. Toxins, medicines, and hazardous items were inaccessible during today's inspection.

There is a screened fireplace in the family room (day care area) also blocked by furniture. The home has a fully charged 3A40BC fire extinguisher locate in the garage. Licensee also had a smaller Kitchen fire extinguisher for kitchen fires located in the kitchen. Smoke alarms and a carbon monoxide detector (all tested and functioning), and a working telephone. Fire Drills are conducted monthly, the last drill was completed on 4/14/2022.

The licensee CPR and First Aid certificate are current and expires on 7/10/2023; Mandated Reporter training is not available in licensee’s native language and therefore the requirement is waived until it becomes available. All adults living in the home were in compliance with all other immunization laws which pertains to day care providers.
M
LPA reminded licensee of the following: CPR/First Aid must be renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility. LPA did not observe any bodies of water hazardous materials, or toxins accessible to children on the premises during the inspection.

At 9:50am, children's files were reviewed. All files were complete and well organized. The licensee owns the property, does not carry liability insurance. All LIC 282 forms Notice of no Liability Insurance signed and dated in each child’s file.

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.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAH, HINA
FACILITY NUMBER: 013422337
VISIT DATE: 04/28/2022
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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

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.

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/inspection-process.

There were 2 deficiencies issued today, see LIC809D. A copy of this report will remain on file for three years.



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

Exit interview conducted and report was reviewed with the licensee Hina Shah.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2022 01:16 PM - It Cannot Be Edited


Created By: Russell Haderer On 04/28/2022 at 12:48 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SHAH, HINA
FACILITY NUMBER: 013422337

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in there were four infants and three preschool children in care today, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Licensee called one infant and preschool child's mothers to come pick up their child during LPA's visit. LPA will return to ensure Licensee is remaining within ratio. Licensee is also advised watch video on "How Many Children Can Attend a Family Child Care Home?" at WWW.CCLD.CHILDCAREVIDEOS.ORG. Submit statement of understanding by 5/3/2022. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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