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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624895
Report Date: 04/11/2023
Date Signed: 04/11/2023 10:40:12 AM

Document Has Been Signed on 04/11/2023 10:40 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:MOMAND, SHAHIMAFACILITY NUMBER:
343624895
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/11/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shahima MomandTIME COMPLETED:
10:50 AM
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At 9:30 a.m. on Tuesday, April 11th, 2023, Licensing Program Analyst (LPA) Karyn Guerra met with Applicant, Shahima Momand, for the purpose of an announced prelicensing, change of location inspection. Applicant was previously licensed at facility number 343624056. Applicant understands that the old facility number will be closed as of this date and they are longer able to operate in previous location. Licensee’s spouse was also present during today’s inspection and provided translation assistance. Hours of operation are 8:00 a.m. - 10:00 p.m., Monday thru Friday.

All individuals subject to criminal background review have obtained a criminal record clearance. 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.

Applicant guided LPA on a tour of the facility. The single story apartment home is on the first floor of the complex and consists of 2 bedrooms, 1 bathroom, kitchen and living room and patio. There are no off limits areas of the home. LPA observed functioning smoke and carbon monoxide detectors, and a 2A10-BC fire extinguisher. LPA reviewed the required postings. Cleaning materials, hazardous items, knives, and medications are all stored inaccessible to children. There is a fenced pool on the apartment complex grounds. Applicant stated that there are no weapons nor poisons in the home. There is a metal covering over the wall heater. Applicant will also use a gate to prevent hall access to wall heater. LPA reviewed capacity increase requirements and ratios.

report continued on 809-C.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MOMAND, SHAHIMA
FACILITY NUMBER: 343624895
VISIT DATE: 04/11/2023
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Applicant rents the home and provided proof of control of property via lease agreement. Applicant has completed the required Preventative Health and Safety course. Applicant's current in person EMSA approved CPR and First Aid certification was verified and expires February 2025. Applicant was reminded that CPR/First Aid certification shall be renewed every two 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. 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.

As of today 4/11/2023, facility is approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2. Applicant understands that Landlord consent is required for a capacity of 8 children.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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