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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494902
Report Date: 08/30/2021
Date Signed: 08/30/2021 02:34:56 PM

Document Has Been Signed on 08/30/2021 02:34 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:SIDDIQUI FAMILY CHILD CAREFACILITY NUMBER:
197494902
ADMINISTRATOR:ASMA SIDDIQUIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 376-8950
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
08/30/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Asma Siddiqui, ApplicantTIME COMPLETED:
02:50 PM
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On August 30, 2021 at 1:30 PM, Licensing Program Analyst (LPA) Miriam Cohen conducted an announced Pre-Licensing inspection. The purpose of the meeting was to ensure that health, safety and personal rights, as required by Title 22 Regulations governing California Family Child Care Homes, will be met by the applicant, Asma Siddiqui. This is an application located at 1931 253rd Street Lomita, CA 90717 for a Large Family Child Care Home with maximum capacity for 14 children – no more than three infants, one child in kindergarten or elementary school, and one child at least six years or older. The family childcare home will operate Monday thru Friday from 6:00 AM - 6:00 PM. LPA met with applicant and was guided on a tour of the indoor and outdoor of the home. The home is a one-story dwelling with six bedrooms and two bathrooms. The master bedroom and four guest bedrooms are off-limits and made inaccessible to day care children using child proof doorknobs. Family members residing in the home consist of the following: the applicant, spouse, elderly mother, and three under age children (two males ages 15 and 12 and one female age seven).
The main day care area shall be conducted in the bedroom located in the back of the house for daytime activities and sleeping accommodation. The bathroom (with toilet, sink, and tub) located in the hallway adjacent to the kitchen shall be accessible to children in care. The kitchen cabinets and drawers shall be latched and made inaccessible to children in care. Sharp objects and knives as placed on top of the shelf. Chemicals, cleaning supplies, and poisons are kept in the laundry room made inaccessible to children. The backyard is accessible to children for outdoor activities. An attached garage is off limits and made inaccessible to day care children using special lock and key. All areas of the home were inspected according to the LIC. 999A- facility sketch.
LPA Cohen observed the Following:
*Fire safety requirements: Fully charged fire extinguisher (minimum rating 2A:10BC), smoke and carbon monoxide detectors present and operable
*Applicant is currently certified in Pediatric CPR/First Aid with the required eight hours’ nutrition class
*Toys and equipment are observed and in good repair
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Miriam Cohen
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SIDDIQUI FAMILY CHILD CARE
FACILITY NUMBER: 197494902
VISIT DATE: 08/30/2021
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* The home is equipped with a first-aid kit: Cleansing pads, band aid, bandages, gauze, and a digital thermometer.
*All toxins and detergents are in locked/latched cabinets
*Home has central heating and air condition
*Electrical outlets have safety covers installed
*Applicant states that there are no guns/weapons in the home
*LPA did not observe firearms and other dangerous weapons during the inspection
*LPA observed one pet turtle in the backyard
*LPA Cohen did not observe bodies of water
The following items were thoroughly discussed with the applicants:
*Requirements for fire drills, earthquake drills, and documentation for both
*The necessity of earthquake safety and drills twice a year
*The role and responsibilities of being a mandated reporter
*Mandatory Forms for the children’s files and provider’s files
*Applicant was referred to LIC 311D: Records to be Maintained at The Facility - Family Child Care Home.
*Applicant was made aware that it is their responsibility, as well as anyone who assists in providing care, to know Title 22 Regulations.
*The applicant was advised on how to access forms and Regulations for Family Child Care online at
www.ccld.ca.gov
*The applicant was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must have the facility’s phone number at all times. If the phone number has changed, licensing must be notified.
*Regulation prohibits the smoking of tobacco on the premises
*State law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category
*All infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome)
*Applicants were informed that all provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. Safe to Sleep Campaign:
https://safetosleep.nichd.nih.gov/materials19-02 CCP Safe Sleep Awareness Campaign
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Miriam Cohen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SIDDIQUI FAMILY CHILD CARE
FACILITY NUMBER: 197494902
VISIT DATE: 08/30/2021
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*Only children eating may be in highchairs and that car seats are utilized only for transportation.
*Requirements for fingerprint clearances and associations are discussed with the licensee.
The applicant was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day up to $500.00 (5 days) for the 1st offense and up to $3000.00 for the 2nd offense within a 12-month period. The applicant may find additional information and forms on the Department’s website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507.
*LPA Cohen informed applicants how to obtain Quarterly Updates. Applicants were encouraged to read the Child Care Quarterly updates every season, as they come out, to stay informed of any changes or updates to statutes and regulations. The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on childcare licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541
Email Address: childcareadvocatesprogram@dss.ca.gov
*The applicant was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and licensing within the time frame specified by the regulation.
*The "Notification of Parent's Rights" (PUB394) poster must be posted in an area accessible to parents.
*The applicants were advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days.
*LPA discussed AB633 and informed applicant that upon receipt of a Type A deficiency, the applicants shall post and provide copies of this licensing report (LIC 809 or LIC 9099 and copy of LIC 9224 to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed.
*Complaints shall be reported by applicant/licensee and/or parents to the complaint hotline at (844) 538-8766 and for general information and incident reporting; contact their local childcare office.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Miriam Cohen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SIDDIQUI FAMILY CHILD CARE
FACILITY NUMBER: 197494902
VISIT DATE: 08/30/2021
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*Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a childcare facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the inspection.
*Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Website: www.mandatedreporterca.com Applicants were reminded of their responsibility to report suspected child abuse.
*Incidental Medical Services Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Carrying out medical orders when the child’s physician has determined that a layperson can be trained and safely carry out the orders. Incidental Medical Services (IMS) policy was discussed. 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
*New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.
*Applicant was informed of the following items that must be posted in visual site once licensed:
(1) License (2) Emergency Disaster Plan (3) Children’s Roster (4) Parents Rights Poster PUB 394, Personal Rights LIC 613-A Recent regulatory changes were discussed.

CAPACITY LICENSE:
While operating as a large family childcare home Applicant may operate one of 3 ways: 4 infants only. Maximum Capacity 6 children with no more than 3 infants and 3 children over the age of 2 years old. Maximum Capacity 8 children with no more than 2 infants, and 2 children who are enrolled in kindergarten or elementary school and 4 children two years old or above.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Miriam Cohen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SIDDIQUI FAMILY CHILD CARE
FACILITY NUMBER: 197494902
VISIT DATE: 08/30/2021
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Below are forms, found at www.ccld.ca.gov, that applicants shall use for record keeping and posting requirements:
LIC 9040 Child Care Facility Roster (Retain for 3 years) most recent must be posted
LIC 9148 Earthquake Preparedness Checklist
LIC 627 Consent for Medical Treatment
LIC 702 Child's Preadmission Health History-Parents Report
LIC 995 Notification of Parent's Rights
PUB 394 Notification of Parent's Rights Poster 12/06 (issued & discussed)
LIC 613-A Personal Rights
LIC 700 Identification and Emergency Information
LIC 282 Affidavit Regarding Liability for Family Child Care Homes
LIC 9224 Acknowledgement of Receipt of Licensing Reports 12/06 (issued & discussed)
Title 22, Division 12 Regulations (access website: http://ccld.ca.gov)

A copy of this report was emailed to applicants with instruction to reply to the email, which will serve as a signature.

An exit interview was conducted with the above items discussed and a copy of this report was provided to applicant, Asma Siddiqui.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Miriam Cohen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC809 (FAS) - (06/04)
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