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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422602
Report Date: 11/18/2021
Date Signed: 11/18/2021 11:26:39 AM

Document Has Been Signed on 11/18/2021 11:26 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:RAHIMI, HAFSAFACILITY NUMBER:
013422602
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Hafsa Rahimi- LicenseeTIME COMPLETED:
11:35 AM
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On 11/18/21 at 10:34am, Licensing Program Analyst (LPA) Briana Plumboy conducted an unannounced Case Management Inspection with Licensee Hafsa Rahimi. Present for the inspection was 1 infant, 4 preschool age children in care as well as fingerprint clear and associated assistant Lailoma Sarag. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 8:00am until 6:00pm.

ON LIMITS: the family room, downstairs bathroom, dining/living room, and backyard

OFF LIMITS: entire second floor, the garage, and the kitchen

There is a child safety gate located across the kitchen, another child safety gate at the step located between the restroom and family room, and another child safety gate located at the bottom of the stairs. The ISOLATION AREA will be the living room. The BACKYARD play area is completely fenced. Per licensee, the children play in the center part of the backyard, and not on the sides of the home. There is a 3A40BC fire extinguisher, carbon monoxide detector, pull down fire alarm, and smoke detectors which meet State Fire Marshall standards during today's inspection.
Per licensee, there are no firearms in the home. There are no pets in the home. All required licensing documents are posted and visible for public review. The licensee's Pediatric CPR/First Aid certificate is current and expires 7/7/23. Licensee's mandated reporter training was completed on 7/9/21. Licensee is in compliance with the immunization law.

See 809-C for continuance
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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: RAHIMI, HAFSA
FACILITY NUMBER: 013422602
VISIT DATE: 11/18/2021
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On 11/18/21, a fire clearance was granted to facility #013422602. Per the 850 approved Fire Clearance at no time shall children in care be in the garage, second story of the home, or the kitchen. All documents have been received for the increase of capacity application. 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.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov .

As of 11/18/21, this home is recommended for an increase of capacity. There are no deficiencies cited today. The report will remain on file for three years. A notice of site visit was provided, and the licensee was reminded to have it posted for 30 days. This entire report has been read to the Licensee by LPA Plumboy. The licensee is aware the signature on this report confirm receipt of these documents. LPA asked the licensee if the licensee had any questions pertaining to any aspects including, but not limited to, any part of this report and of the documents given to the licensee, and per licensee, there are no further questions at this time. Licensee is aware at anytime she can reach out to LPA Plumboy or CCLD. An exit interview was conducted, and appeal rights provided.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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