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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100700
Report Date: 05/17/2021
Date Signed: 05/17/2021 03:35:06 PM

Document Has Been Signed on 05/17/2021 03:35 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:SHAMOON, WARDYAH FAMILY CHILD CAREFACILITY NUMBER:
376100700
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/17/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Wardyah ShamoonTIME COMPLETED:
03:45 PM
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On 5/17/2021 at 1:30PM, Licensing Program Analyst(LPA) Nancy Diaz conducted an announced Pre-Licensing inspection for a change of location with the applicant, Wardyah Shamoon. Due to COVID-19 pandemic restrictions, this inspection was completed virtually via Facetime. Applicant's daughter, Maryam was also present and helped translate in Qaldian.

This 4-bedroom, 2-bathroom single family home was toured and inspected to ensure an environment safe for the care and supervision of children.

Applicant maintains smoke and carbon monoxide detectors and fire extinguisher in the home that meets regulation requirements. Both detectors were tested today and deemed to be operable. All hazardous items were latched and secured under the kitchen cabinets/drawers and are out of reach of children. Mrs. Shamoon stated that she does not maintain any weapons or bodies of water. Applicant maintains a first aid kit in the home.

A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Control of property was provided to the department via copy of deed of trust. First Aid and CPR will expire on February 2022 and Preventative Health Practices course was completed on 3/16/2016. Mrs. Shammon completed "Lead Poisoning Prevention" on 5/11/2021. Mandated Reporter Training was waived due to limited English proficiency of applicant. Mrs. Shamoon's primary language is Qaldian.

The daycare children will have access to: living room, dining room, kitchen, family room, Bathroom #1, Backyard, Bedroom #1 and Bedroom #2. Off limit areas are: Bedroom #3, Bedroom #4, Bathroom #2 and garage. The garage shall be locked when children are present.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2021
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: SHAMOON, WARDYAH FAMILY CHILD CARE
FACILITY NUMBER: 376100700
VISIT DATE: 05/17/2021
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The new provider packet was reviewed with the applicant including information on child abuse reporting, children’s records, immunizations, adults living or working in the home, SIDS, Incidental Medical Services, and the YMCA Resource Center. Applicant was reminded that corporal punishment, smoking, walkers, exersaucers, jumpers and bouncy seats are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed Shaken Baby Syndrome and California Megan's Law and LPA provided: www.meganslaw.ca.gov.

Applicant submitted a COVID-19 self-assessment form.
Applicant and LPA discussed COVID-19 guidelines and how to prevent spread of the virus. Applicant has posted COVID-19 posters in facility. Applicant was provided COVID-19 resources and directed to website: https://www.cdss.ca.gov/inforesources/community-care-licensing to receive important updates and information.

Any minor upon his/her 18th birthday must be fingerprinted within 30 days. Applicant has met all immunization requirements per SB792 and have completed the AB1207 Mandated Reported Training. Applicant is reminded to make anything that reads, "Keep Out of Reach of Children" inaccessible to children.

Applicant states that she will comply with all regulations and laws governing family child care homes and that she is financially secure to operate a family child care home for children. LPA reviewed this report with Applicant prior to obtaining her signature.


LPA discussed and provided applicant with the following: Child Care Advocates - email address childcareadvocatesprogram@dss.ca.gov and phone number (916) 654-1541.In addition, for common questions or questions regarding licensing requirements to contact the Child Care Licensing duty line at 619-767-2248.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: SHAMOON, WARDYAH FAMILY CHILD CARE
FACILITY NUMBER: 376100700
VISIT DATE: 05/17/2021
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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: http://www.ada.gov/childqanda.htm

Child Care Providers can now sign up for Quarterly Updates and PINS through the DSS website. Please go to www.ccld.ca.gov and click on Child Care, go under Quick Links and Quarterly updates, click on “Receive Important Updates” then enter your email address and choose which program(s) you would like to subscribe to and click “subscribe”.

CORRECTIONS NEEDED PRIOR TO LICENSURE:

- Submit an updated LIC279B.
- Make bedrooms #3 and #4 inaccessible to children.
- Remove tires, adult bikes, lumber, wooden pile and other debris from the backyard and make it inaccessible to children.
- Post required froms (LIC 610A, Parents Rights, LIC 999A, Car seat law) and COVID-19 information.

Applicant shall contact this LPA when all corrections are completed. Applicant stated that she will have corrections completed no later than
May 31, 2021.

An exit interview was conducted with the applicant. Appeal Rights (LIC9058) will be sent along with the report (LIC809) via e-mail to the Applicant. Applicant will confirm receipt of this report via e-mail and the reply of confirmation will serve as the signature acknowledging these rights. The Notice of Site Visit (LIC9213) must remain posted for 30 days.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
LIC809 (FAS) - (06/04)
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