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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627808
Report Date: 10/12/2021
Date Signed: 10/12/2021 02:39:23 PM

Document Has Been Signed on 10/12/2021 02:39 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:MOHAMED, MARIAM FAMILY CHILD CAREFACILITY NUMBER:
376627808
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mariam MohammedTIME COMPLETED:
01:00 PM
NARRATIVE
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On 10/12/21 at 9:00 AM Licensing Program Analyst (LPA) Adrian Mangina conducted an unannounced Annual inspection with the Licensee. Upon arrival, LPA met with Licensee, Mariam Mohammed. The one-story three-bedroom two-bathroom first floor apartment was toured and inspected to ensure an environment safe for the care and supervision of children. Also present in the home were Licensee’s husband Mohamoud Kassim and four day care children. At 11:49 AM Licensee left to pick up a fifth child from school. and returned at 12:05 PM. Proper supervision and ratios were observed. The 2A10BC fire extinguisher located in the kitchen and combination carbon monoxide detector and smoke detector located in the living room meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. There are no bodies of water on the property. Licensee states that there are no weapons 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. Licensee was reminded that all adults 18 and over, 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 Child Care Center. 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.

Licensee’s First Aid and CPR certifications expire on 8/22/2022. Helper’s First Aid and CPR certifications expire on 8/22/2022. Licensee completed Mandated Reporter Training on 10/8/2021. Helper’s Mandated Reporter Training expired 2/4/2021. Licensee states that her husband also attempted to take Mandated Reporter Training on 10/8/21 but is having trouble getting the course to load under his log in. Licensee demonstrated to LPA how neither the General Course or the Childcare Provider Specific course will load. Licensee will contact mandatedreporterca.com today and request assistance. Licensee meets immunization requirements. Licensee advised Mandated Reporter Training waived due to first language is not English. Helper Mohamoud Kassim has immunization record but is missing MMR vaccine. Licensee

(continued on LIC809 page 2)

SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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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Document Has Been Signed on 10/12/2021 02:39 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 10/12/2021 at 11:58 AM
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: MOHAMED, MARIAM FAMILY CHILD CARE
FACILITY NUMBER: 376627808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as helper Mohamoud Kassim's immunization record does not have proof of MMR vaccine which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Licensee will ensure that helper Mahamoud Kassim obtains MMR vaccine or antibody test showing immunity to measles and provide proof to LPA no later than close of business on 11/10/21.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two of six children (child #4 and Child #5) do not have immunization record in file. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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LIcensee will obtain immunization records for child #4 and Child #5 no later than 11/10/21 and will provide records for those children to LPA no later than close of busienss 11/10/21.
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: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021


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: MOHAMED, MARIAM FAMILY CHILD CARE
FACILITY NUMBER: 376627808
VISIT DATE: 10/12/2021
NARRATIVE
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LC809 page 2

Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include: living room, dining area, kitchen, and bathroom #1. Off limits areas include: master bedroom and master bathroom, bedroom #1 and Bedroom #2 and are inaccessible through use of latches, locks, doorknob covers and safety gates. There is a working phone at the facility. The licensee has sufficient safe, age appropriate toys and equipment available. The home has a fully fenced backyard available for outdoor activities There is a trampoline that has a mesh fence surrounding it which Licensee states is used by children in care. Licensee was advised that visual supervision is required at all times when children are on the trampoline. Licensee states that she will soon install a storage shed and will provide LPA with an updated LIC999A per regulation.

Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, ensure that all adults living or working in the home have criminal background clearances associated to the facility, corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov. LPA Mangina reviewed Covid-19 guidelines with Licensee and provided Covid-19 resources. LPA Mangina directed Licensee to website: https://www.cdss.ca.gov/inforesources/community-care-licensing to receive important updates and information.

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.

(continued on LIC809 page3)

SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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: MOHAMED, MARIAM FAMILY CHILD CARE
FACILITY NUMBER: 376627808
VISIT DATE: 10/12/2021
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(LIC809 page 3)

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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

See LIC809 D for deficiencies cited and Technical Assistance given.

An exit interview was conducted with the Licensee Mariam Mohammed. The Licensee was provided a copy of their appeal rights (LIC 9058) along with a copy of this the report (LIC809) their signature on this form acknowledges receipt of these rights. LPA observed LIC 9213 (Notice of Site visit) was posted during today's visit. Notice of Site Visit must remain posted for 30 days.

SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC809 (FAS) - (06/04)
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