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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624357
Report Date: 07/11/2023
Date Signed: 07/12/2023 08:46:00 AM

Document Has Been Signed on 07/12/2023 08:46 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAFI, KARISHMAFACILITY NUMBER:
343624357
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Karishma SafiTIME COMPLETED:
02:20 PM
NARRATIVE
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On July 11, 2023 at 11:00 AM, Licensing Program Analysts (LPAs) Tanya Washington and Dao Pa Vang met with Licensee, Karishma Safi, for the purpose of an unannounced, required - 1 year inspection. Upon arrival Licensee, her mother, adult brother, three minor siblings and two daycare children were present in the home. Licensee's brother Mudassir provided interpretation from English to Pashtai.

Licensee was reminded that any of their own children under 10 years count toward the child care ratio when present during child care hours. Facility operating hours are Monday -Friday from 8 AM to 6 PM. Licensee stated that she has a split schedule for children and some of them attend in the AM and some in the PM. Off limit areas consist of entire second floor, laundry room and outdoor area. Licensee understands that child care children shall not enter these off limits areas of the home. LPAs observed a gate at the bottom of the stairs, Licensee understands that the safety gate must be installed whenever children under five years old are present.

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 provided Live Scan form for newly adult child.

A health and safety inspection was conducted in all areas of the home including off limit areas. LPAs observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke detector. Facility did not have a functioning carbon monoxide detector. Licensee stated that there are no weapons nor poisons in the home. Toxic and hazardous items were appropriately stored, inaccessible to children. There is no fireplace in the home. Licensee has never conducted a fire drill since becoming licensed. Licensee indicated that she has 14 children enrolled, however she did not have any required licensing documents or vaccine records for children. Licensee did not have a children's roster.

Report continued on LIC809C.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SAFI, KARISHMA
FACILITY NUMBER: 343624357
VISIT DATE: 07/11/2023
NARRATIVE
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Licensee did not have verification of EMSA certified CPR and First Aid, her last certification expired 08/2022. Licensee was reminded that EMSA CPR and First Aid certification shall be renewed every 2 years.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. At 11:56 AM, LPAs observed Child #1 attempt to get out of the Graco Pack n' Play. Licensee has an infant insert inside the Pack n' Play for babies who are not able to climb out. Child #1 is capable of climbing out and the infant insert must be removed when Child #1 uses the Pack n Play. LPA 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 that no infants shall be swaddled during child care hours and must placed to sleep in an approved standard crib or play yard. Licensee has never kept record of infant safe sleep log since becoming licensed. Technical assistance was provided.

This provider is not currently providing Incidental Medical Services IMS services to children in care. 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: https://www.ada.gov/childqanda.htm.

A staff interview was conducted with the Licensee. The department's inspection authority was discussed. Annual fees are passed due and must be paid as soon as possible. LPA provided Licensee with a PIN code to make a payment online. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates.

Report continued on LIC809C.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SAFI, KARISHMA
FACILITY NUMBER: 343624357
VISIT DATE: 07/11/2023
NARRATIVE
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LPA reminded the Licensee that although the Mandated Reporter training is not required for the application, training can still be obtained online at www.mandatedreporterca.com or through Child Action as they offer training in other languages.

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.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/ guardians of children who are currently enrolled as well as parents/ guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must acknowledge receipt of this report and citation by signing a LIC9224, “ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS”. A copy of this form should be placed in each child file upon receipt from parent.

LPA reviewed this report with Licensee and provided a copy of appeal rights. 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.




SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/12/2023 08:46 AM - It Cannot Be Edited


Created By: Tanya Washington On 07/11/2023 at 12:51 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAFI, KARISHMA
FACILITY NUMBER: 343624357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

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 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Licensee stated she will pruchase batteries for the carbon monoxide and ensure that it's functioning by POC date of 07/12/2023.
Type A
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

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 which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed Child #1 in a Pack n Play with an infant inserts for babies that are unable to climb out of the Pack N Play. LPAs observed Child #1 attempt to get out of the playyard. This is an immidiate health and safety risk to children in care.
POC Due Date: 07/11/2023
Plan of Correction
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Licensee's brother removed the infant insert. Licensee understands that mobile infants can only be placed in the Pack n Play during rest period and the infant insert must be removed at all times for older infants who are able to climb out.
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:Amanda Blesi
LICENSING EVALUATOR NAME:Tanya Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 07/12/2023 08:46 AM - It Cannot Be Edited


Created By: Tanya Washington On 07/11/2023 at 12:51 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAFI, KARISHMA
FACILITY NUMBER: 343624357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee stated that she has not conducted a fire drill since she became licensed.
POC Due Date: 08/11/2023
Plan of Correction
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Licensee was provided a fire drill log and explained that drill must be conducted and documents at least once every six months.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee stated her CPR and First Aid certification expired 08/2022.
POC Due Date: 08/11/2023
Plan of Correction
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Licensee will sign up for required EMSA certified course by POC date of 08/11/2023.
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:Amanda Blesi
LICENSING EVALUATOR NAME:Tanya Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/12/2023 08:46 AM - It Cannot Be Edited


Created By: Tanya Washington On 07/11/2023 at 12:51 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAFI, KARISHMA
FACILITY NUMBER: 343624357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee stated she currently has 14 children enrolled through Child Action. Licensee only had attendance forms from the agency. Licensee did not have any required licensing documents or vaccination records for children.
POC Due Date: 08/11/2023
Plan of Correction
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Licensee was provided all required forms including form LIC311D. LPAs went over every form with Licensee and her brother provided interpretation. Licensee stated she understands that the forms provided are required to be filled out for all currently enrolled children. Licensee also stated she understands that the forms are required for new children prior to enrollment.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee was not aware of this requirement.
POC Due Date: 08/11/2023
Plan of Correction
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LPAs provided blank LIC9040 and explained that all children enrolled must be listed on the roster.
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:Amanda Blesi
LICENSING EVALUATOR NAME:Tanya Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
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