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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625694
Report Date: 07/03/2024
Date Signed: 07/03/2024 10:57:52 AM

Document Has Been Signed on 07/03/2024 10:57 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:HAZEM, ANISA & HAZEM, SAIFURAHMANFACILITY NUMBER:
343625694
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
07/03/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Anisa HazemTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On Wednesday, July 3, 2024, at approximately 10:00 AM, Licensing Program Analyst (LPA) Josiah Gathing, met with Licensee Anisa Hazem, to conduct a Case Management inspection for the purpose of increasing the maximum capacity from 8 to 14 children. During the inspection there were no children being supervised by Licensee. LPA conducted a health and safety inspection of all areas accessible to children. Off limit areas consist of: Upstairs bed/bath and garage.

The Fire Safety Inspection Clearance was granted on June 27, 2024. CPR/First Aid certificate is current and expires: August 28, 2026. The posted License, Parent's Rights, Emergency Disaster Plan are being maintained by the Licensee. Hazardous items were stored inaccessible to children in care. Per Licensee, there are no firearms in the home. Fire extinguisher (2A10BC), carbon monoxide detector, smoke detector, and pull alarm meet regulation. The outdoor area used by children at this time is fenced and age-appropriate toys were observed. The Licensee understands that 100% supervision is required in any unfenced areas. Pool was fenced according to regulation with a self-latching gate. Licensee understands that prior to making alterations or additions to the home or grounds, the licensee shall notify the Department of the proposed changes. During the inspection, LPAs discussed ratio and capacity requirements.

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 submitting 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

Report continues on 809C…
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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: HAZEM, ANISA & HAZEM, SAIFURAHMAN
FACILITY NUMBER: 343625694
VISIT DATE: 07/03/2024
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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 discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://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.

In the areas that were evaluated, no deficiencies were observed at the time of the inspection. A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Licensees, Anisa and Saifurahman Hazem.



Capacity increase is approved as of today, July 3, 2024. The facility is licensed to serve a MAX. CAP (WHEN THERE IS AN ASSISTANT PRESENT): 12 - NO MORE THAN 4 INFANTS. CAP 14 - NO MORE THAN 3 INFANTS. 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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