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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422337
Report Date: 06/17/2022
Date Signed: 06/17/2022 11:51:56 AM

Document Has Been Signed on 06/17/2022 11:51 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
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: 4DATE:
06/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Hina ShahTIME COMPLETED:
11:55 AM
NARRATIVE
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On June 17, 2022 at approximately 10:00am Licensing Program Analyst (LPA) Haderer arrived for an unannounced case management visit for a capacity change inspection. Present in the home today was licensee Hina Shah, her fingerprint cleared and TB tested husband, 4 children in care (all infants aged from 15 months to 23 months old). The facility is in ratio today. Hours of operation remain the same at 9:00am to 6:00pm.

All requested documents were received for the increase of capacity application. The fire clearance for a capacity of 14 was approved by the Fremont Fire Department on 05/18/2022 (received by Licensing on 6/16/2022). The Licensee is reminded to abide by the conditions of the fire clearance (second floor and garage is off limits to children). Pull down fire alarm has been installed in the living room near the front door.

The Licensee was reminded that an assistant is needed with a large family child care home license, and whenever an assistant is not present, the licensee will comply with the capacity requirements for a small family child care home. A copy of the approved children ratios was printed and given to licensee.

Requirements for assistants:
Fingerprint clearance
LIC 501 Personnel Record Application (or job app)
LIC 508 Criminal Record Statement
LIC 9052 Employee Rights (signed by employee)
Immunization for: MMR, tdap, influenza and a negative TB test (or x-ray clearance)
Assistant / helper has CPR/1st Aide if ever left alone with children
Mandated Reporter (current within 2-years, not expired)
LIC 9108 Statement Acknowledging requirement to report child abuse
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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: 06/17/2022
NARRATIVE
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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, 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.
The licensee’s CPR and First Aid certificates are current and expire 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.
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.

There was one Type B deficiency issued today for no Infant Sleep logs, see LIC809D. LPA also reviewed guidance on operating safely during the Covid pandemic.

This home is recommended for an increase of capacity as of 06-17-2022. The 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: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2022 11:51 AM - It Cannot Be Edited


Created By: Russell Haderer On 06/17/2022 at 11:27 AM
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: 06/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2022
Section Cited
CCR
102425(j)(2)(D)

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102425 Infant Safe Sleep
(j) The provider shall supervise infants while they are sleeping and.....:
(2)(D) Documentation shall be maintained in the infant’s file and be available to the Department for review.
Documentation shall include: a.Date. b.Infant’s name. c.Time of each 15-minute check.
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From this day going forward, Licensee will maintain infant sleep logs for all infants from birth to 24 months.
These logs must be kept daily and stored for 3 years.
All logs/reports must be available for Licensing Department for review.
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Based on file review, the licensee did not comply with the section cited above in that there were no Infant Safe Sleep logs being maintained and available for Department review which poses an immediate health, safety or personal rights risk to persons in care.
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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: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
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