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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376624004
Report Date: 05/05/2025
Date Signed: 05/05/2025 03:17:10 PM

Document Has Been Signed on 05/05/2025 03:17 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:IMTIAZ, SYEDA FAMILY CHILD CAREFACILITY NUMBER:
376624004
ADMINISTRATOR/
DIRECTOR:		SYEDA IMTIAZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 451-7658
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
05/05/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:04 PM
MET WITH:Licensee Imtiaz Syeda TIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Kelly Gerth conducted a separate unannounced visit at the at the family childcare.

During the visit, LPA Gerth reviewed records and toured the family childcare with the licensee. The following health and safety concerns were observed during file review and inspection, which resulted in a separate case management visit.

Upon arrival, Licensee greeted LPA, and LPA followed Licensee to outdoor activity area where Licensee was with 4 children. While walking through the daycare LPA observed the stairs to be without a barricade. LPA asked licensee to please place a barricade in place. Licensee placed baby gate as barricade.

During file review, Licensee stated there is not a current daycare roster, 2/8 children in care do not have files and 1/1 infants in care do not have 15 min sleep checks documented.

See LIC 809D for deficiencies cited.

Exit interview was conducted, and a copy of this report, 809D’s and appeal rights were provided to Licensee

A notice of site visit was provided, licensee was informed it must be posted for 30 consecutive days.

NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Kelly Gerth
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/05/2025 03:17 PM - It Cannot Be Edited


Created By: Kelly Gerth On 05/05/2025 at 02:36 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: IMTIAZ, SYEDA FAMILY CHILD CARE
FACILITY NUMBER: 376624004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2025
Section Cited
CCR
102417(g)(3)

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(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded. The requirment was not met as evidenced by:
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Licensee will submit a written statement to CCL by POC date, confirming understanding of the regulation and requirment.
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 counts, where the stairs to the second floor were not properly barricaded/made inaccessible during daycare hours, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
05/19/2025
Section Cited
CCR102417(g)(8)

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(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 will submit a current roster to CCL by POC date.
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 counts, where the Licensee did not have a current roster on file, which poses/posed a potential health, safety or personal rights risk to persons 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.
Carlos Martinez
NAME OF LICENSING PROGRAM MANAGER:
Kelly Gerth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/05/2025 03:17 PM - It Cannot Be Edited


Created By: Kelly Gerth On 05/05/2025 at 02:55 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: IMTIAZ, SYEDA FAMILY CHILD CARE
FACILITY NUMBER: 376624004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2025
Section Cited
CCR
102425(j)(D)

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(j) The provider shall supervise infants while they are sleeping and adhere to the following requirements: (D)Documentation shall be maintained in the infant’s file and be available to the Department for review.
This requirement was not met as evidenced by:
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Licensee agrees to submit proof of 15 min sleep logs completed, for all infants aged 24 months and under, by POC date.
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 counts, where the Licensee did not have proof of a sleep log for infant in care, poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
05/12/2025
Section Cited
CCR102418(a)

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(a) (a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
This requirement was not met as evidenced by;
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Licensee agrees to submit proof of immunizations prior to children returning to daycare, or proof of disenrollment of the children by POC date.
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Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 8 children did not have files available for review, including immunizations, which poses/posed a potential health, safety or personal rights risk to persons 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.
Carlos Martinez
NAME OF LICENSING PROGRAM MANAGER:
Kelly Gerth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
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