<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628469
Report Date: 10/21/2021
Date Signed: 10/21/2021 01:18:39 PM

Document Has Been Signed on 10/21/2021 01:18 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:JIMALE, AHADO FAMILY CHILD CAREFACILITY NUMBER:
376628469
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Ahado JimaleTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On October 21, 2021 at 9:46 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted an unannounced Annual Required Inspection and met with Licensee Ahado Jimale. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. One (1) child and the Licensee were present in the facility during this inspection; this child is the Licensee’s grandchild. This facility is a one story, four (4) bedroom, three (3) bathroom house. Licensee accompanied LPA inside and out of the facility during this inspection. The following areas used for childcare are: living room, kitchen, master bedroom and bathroom. The remaining bedrooms and bathroom and are made inaccessible through use of doorknob covers.

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements. Hazardous items were observed inaccessible to children during this inspection. The Licensee has available toys, play equipment and materials. The home has an available fenced backyard for outdoor activities. Licensee was reminded that continuous supervision is to be given to children whenever engaged in outdoor activities. No bodies of water were observed on the premises during the inspection. Licensee stated there are no weapons in the home. Licensee’s First Aid and CPR certifications expire on 06/06/2023. Licensee has required immunizations. Licensee is currently exempt from the Mandated Reporter Training. There is no facility roster. The last fire and disaster drills were conducted and documented on 07/15/2021.

Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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 currently cares for children 24 months or younger. LPA discussed the safe sleep regulations with
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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 18
Document Has Been Signed on 10/21/2021 01:18 PM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 10/21/2021 at 10:55 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: JIMALE, AHADO FAMILY CHILD CARE
FACILITY NUMBER: 376628469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations and an interview with the Licensee, the licensee did not comply with the section cited above in that five of five children do not have copies of immunziation records retained in the facility files, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2021
Plan of Correction
1
2
3
4
The Licensee agrees to obtain copies of all daycare children's immunization records and provide LPA with copies of those records no later than 11/30/2021.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(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 is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations and an interview with the Licensee, the licensee did not comply with the section cited above in that there is no completed child roster, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2021
Plan of Correction
1
2
3
4
LPA provided Licensee with blank LIC 9040 Child Care Roster forms. Licensee agrees to complete this form and provide LPA with a copy of the completed roster no later than 11/30/2012.
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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
Page: 5 of 18
Document Has Been Signed on 10/21/2021 01:18 PM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 10/21/2021 at 10:55 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: JIMALE, AHADO FAMILY CHILD CARE
FACILITY NUMBER: 376628469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview with the Licensee, the licensee did not comply with the section cited above in that one of one children 12 months and younger did not have an Individual Infant Sleeping Plan, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2021
Plan of Correction
1
2
3
4
LPA provided Licensee with blank copies of the LIC 9227 form. Licensee agrees to complete this form with the child's parent and provide LPA with a copy of the completed form no later than 11/30/2021.
Type B
Section Cited
CCR
102425(c)(1)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This plan shall be signed and dated by the infant’s authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview with the Licensee, the licensee did not comply with the section cited above in that one of one children 12 months and younger did not have an Individual Infant Sleeping Plan signed and dated by the child's parent, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2021
Plan of Correction
1
2
3
4
LPA provided Licensee with blank copies of the LIC 9227 form. Licensee agrees to complete this form with the child's parent and provide LPA with a copy of the completed form no later than 11/30/2021.
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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
Page: 8 of 18
Document Has Been Signed on 10/21/2021 01:18 PM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 10/21/2021 at 10:55 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: JIMALE, AHADO FAMILY CHILD CARE
FACILITY NUMBER: 376628469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview with the Licensee, the licensee did not comply with the section cited above in that one out of one child 12 months and younger did not have a documented 15 minute check, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2021
Plan of Correction
1
2
3
4
The Licensee agrees to devise her own form for documenting 15 minute sleeping checks on children 12 months and younger. She agrees to have the following, but not limited to: the date of the check, the times of the 15 minute checks, the name of the checked child and the initials of the individual who conducted the 15 minute check on the form. Licensee agrees to provide LPA with a copy of this form no later than 11/30/2021.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
Page: 12 of 18
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: JIMALE, AHADO FAMILY CHILD CARE
FACILITY NUMBER: 376628469
VISIT DATE: 10/21/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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 [facility representative] 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.

LPA reminded Licensee of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances or exemptions. Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare.

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.

Deficiencies were observed as per California Code of Regulations, (Title 22, Division 12 & Chapter 3), are being cited on the attached LIC 809-D.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Ahado Jimale.

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.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
Page: 4 of 18