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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100700
Report Date: 03/08/2022
Date Signed: 03/21/2022 12:39:52 PM

Document Has Been Signed on 03/21/2022 12:39 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: 1DATE:
03/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Wardya ShamoonTIME COMPLETED:
11:00 AM
NARRATIVE
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On 3/8/22 at 9:57 AM Licensing Program Analyst (LPA) Adrian Mangina conducted a Case Management - Deficiencies. At arrival LPA was granted entry by Licensee’s adult daughter Maryam Galo. Licensee was not at home but arrived at approximately 10:10 AM. Adult daughter Maryam Galo provided translation. Also present in the home were Licensee's husband Romil Galo and one daycare child. Proper supervision and ratios were observed.

During the inspection at 9:57 AM LPA observed that Staff #1 was alone at the facility with the child in care. At approximately 10:00 AM LPA also observed that Staff #1 does not have current CPR/First Aid certification. At 10:20 AM LPA observed that Child#1 does not have a child file and at 10:25 AM LPA observed that the child roster has not been updated to include child #1.

See LIC809-D for deficiencies cited and civil penalty given.

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: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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 03/21/2022 12:39 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 03/08/2022 at 01:09 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: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2022
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 3/29/22. Licensee also states that in future she will update roster the first day that children are enrolled or begin attending/testing the facility.
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Based on file review Licensee's child roster was not current as child #1 was not added to roster which poses a potential health and safety risk to children in care,
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Type B
03/29/2022
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 complete child file to LPA no later than close of business 3/29/22. Licensee also states that in future she will ensure that each child has a complete child file before the child attends the first day at the child care.
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Based on file review Licensee did not have signed LIC995A for child #1 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: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/21/2022 12:39 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 03/08/2022 at 01:15 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: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2022
Section Cited
CCR
102416(c)

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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 was not met as evidenced by:
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LIcensee states will provide CPR/First Aid completion certificate for staff #1 no later than close of business 3/29/2022
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Based on record review and Licensee statement, Staff #1 does has not completed pediatric CPR/First aid as required which poses a potential health, safety and personal rights issue 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: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022


LIC809 (FAS) - (06/04)
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