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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100700
Report Date: 12/22/2021
Date Signed: 12/22/2021 04:48:38 PM

Document Has Been Signed on 12/22/2021 04:48 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: 8CENSUS: DATE:
12/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Wardya Shamoon. Adult daughterTIME COMPLETED:
05:00 PM
NARRATIVE
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On 12/22/2021 at 3:15 PM Licensing Program Analyst (LPA) Adrian Mangina conducted a Case Management Deficiencies. LPA met with Licensee , Wardya Shamoon. Minor child provided translation. Also present in the home were Licensee's husband Romil Galo and one minor child. There were no daycare children present. Proper supervision and ratios were observed.

During the inspection LPA observed that the last disaster drill was 3/4/21. LPA requested child roster and observed that Child#1, Child #2, Child #3 Child #4, Child #5, and Child #6 were not on the child roster and several entries on the form were missing complete information. LPA reviewed child files and found that 18 of 18 child files were incomplete. In addition, LPA observed that child #12 did not have documentation of nap checks in the files.

See LIC809-D for deficiencies cited

Licensee was provided with a copy of this report (LIC809). Their signature on this form is acknowledgement of receipt. A Notice of Site Visit (LIC9213)was also provided and must be posted for 30 consecutive days.
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 12/22/2021 04:48 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 12/22/2021 at 03:56 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: SHAMOON, WARDYAH FAMILY CHILD CARE
FACILITY NUMBER: 376100700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2022
Section Cited
CCR
102417(g)(8)

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OPERATION OF A FAMILY CHILD CARE HOME102417(g)(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 was not met as evidenced by:
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Licensee states will update child roster and provide to LPA no later than close of business 1/12/22.
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Based on file review Licensee's child roster was not current and child 1, child 2, child 3, child 4, child 5 and child 6 were not on list and several other lisitngs were not complete, which poses a potential health and safety risk to children in care,
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Type B
01/12/2022
Section Cited
CCR102419(d)(1)

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ADMISSION PROCEDURES 102419(d)(1):
... licensee shall request...parent...to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent... has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file.
This requirement was not met as evidenced by:
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Licensee states will provide signed LIC995A for every child currently in care to LPA no later than close of businesss 1/12/22.
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Based on file review Licensee did not have signed LIC995A for 18 of 18 children in care which poses a potential health and safety risk to children in care
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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:Renesha Pack
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/22/2021 04:48 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 12/22/2021 at 04:12 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: SHAMOON, WARDYAH FAMILY CHILD CARE
FACILITY NUMBER: 376100700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2022
Section Cited
CCR
102417(9)(a)

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OPERATION OF A FAMILY CHILD CARE HOME 102417(9)(A) each family child care home shall conduct fire drills and disaster drills at least once every six months.
This requirement was not met as evidenced by:
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Licensee will provide LPA with prrof of disaster drill no later than close of business 1/12/22
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Based on record review and Licensee statement Licensee did not conduct a fire drill since 3/4/21 which poses a potential health and safety risk to children in care.
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Type B
01/12/2022
Section Cited
CCR102425(j)(1)

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INFANT SAFE SLEEP 102425(J)(1)The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes

This requirement was not met as evidenced by:
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Licensee will provide Safe Sleep logs for Child #12 to LPA for 12/23/21 through 1/12/22 no later than close of business 1/12/22 and states will keep sleep logs for all children under 2 years old in the future.
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Based on file review Licensee did not document nap checks for Child #12 which poses a potential health and safety risk to children in crae.
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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:Renesha Pack
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
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