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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628469
Report Date: 07/05/2023
Date Signed: 07/05/2023 10:42:16 AM

Document Has Been Signed on 07/05/2023 10:42 AM - 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: 0DATE:
07/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Ahado JimaleTIME COMPLETED:
10:15 AM
NARRATIVE
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On July 5th, 2023, at 7:30 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted an unannounced Annual Required Inspection and met with the Licensee Ahado Jimale. LPA disclosed the purpose of the inspection and was granted facility entry by the Licensee. Only the Licensee and her teen child were present in the facility during this inspection. Amina Hamadi, Licensee's adult daughter, provided telephonic translation as needed. This facility is a four (4) bedroom, three (3) bathroom house. Licensee accompanied LPA during this inspection. The following areas used for childcare are fenced backyard, living room, main bedroom, main bedroom bathroom and the kitchen. The off-limit areas are the remaining bedrooms and bathrooms, which are made inaccessible via door locks.

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. Licensee states children play outside in the fenced backyard. 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 06/03/2025. Licensee has required immunizations. Licensee is currently exempt from Mandated Reporter Training. The facility roster is maintained and was reviewed. At 8:10 AM, Licensee said that no fire/safety drills have been conducted or documented.

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.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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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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: 07/05/2023
NARRATIVE
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LPA provided Licensee with Provider Information Notice (PIN) 20-24-CCP, a blank LIC 9227 “Individual Infant Sleeping Plan” form and two (2) examples of safe sleep logs. 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.

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), and is being cited on the attached LIC 809-D. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the 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: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/05/2023 10:42 AM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 07/05/2023 at 08:38 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: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and Licensee's statement at 8:10 AM, no safety drills have been recently completed, the licensee did not comply with the section cited above in that no safety drill has been recently completed and documented, which poses as a potential health, safety or personal rights risk to children in care.
POC Due Date: 07/26/2023
Plan of Correction
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LPA provided Licensee with a blank Safety Drill Log. Licensee said she will conduct a safety drill and document upon this form before providing LPA with a copy of the completed form by 07/26/2023.
Type B
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and Licensee's statement at 8 and 8:13 AM that the 1 year old sleeps on a bed and is unable to crawl out of a crib, the licensee did not comply with the section cited above in one out of one infant does not sleep in a crib or play pen, which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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LPA and Licensee discussed Safe Sleep Regulations and Sudden Infant Death (SIDS). Licensee states that the infant shall not sleep in the daycare until either a crib or playpen is obtained for him. Licensee said she will obtain a crib or a play pen for the infant and provide LPA with documentation of this purchase no later than 07/26/2023.
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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/05/2023 10:42 AM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 07/05/2023 at 08:38 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: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and Licensee's statement, the infant does not have a current Safe Sleep Log, the licensee did not comply with the section cited above in one of out one infants lacks a current Safe Sleep log, which poses as a potential health, safety or personal rights risk to children in care.
POC Due Date: 07/26/2023
Plan of Correction
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LPA provided Licensee with
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and Licensee's statement, the licensee did not comply with the section cited above in six out of six daycare children did not have a copy of the emergency information card, which poses as a potential safety or personal rights risk to children in care.
POC Due Date: 07/26/2023
Plan of Correction
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LPA provided Licensee with a blank emergency information card. Licensee said she will have each daycare parent complete their children's emergency information card and provide copies of the completed forms to LPA no later than 07/26/2023.
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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 07/05/2023 10:42 AM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 07/05/2023 at 08:38 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: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, record reviews and interview with the Licensee, the licensee did not comply with the section cited above in six out of six daycare children did not have an emergency information card, which poses as a potential health, safety or personal rights risk to children in care.
POC Due Date: 07/26/2023
Plan of Correction
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LPA provided Licensee with a blank emergency information card. Licensee said she will have the daycare parents complete an emergency information card for each daycare children. Licensee said that she will provide LPA with copies of the daycare children's completed emergency information cards no later than 07/26/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 07/05/2023 10:42 AM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 07/05/2023 at 08:38 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: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, record reviews and interview of the Licensee, the licensee did not comply with the section cited above in that six out of six daycare children did not have a completed, dated and signed LIC 995A form on file, which poses as a potential health, safety or personal rights risk to children in care.
POC Due Date: 07/26/2023
Plan of Correction
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LPA provided Licensee with the LIC311D and a blank LIC 995A form. Licensee said she will have all daycare parents complete the LIC 995A forms for each of their children. Licensee said she will provide LPA with copies of these completed forms no later than 07/26/2023.

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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 07/05/2023 10:42 AM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 07/05/2023 at 08:38 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: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record reviews and interview of Licensee, the licensee did not comply with the section cited above in six out of six daycare children did not have the affidavit and Licensee states she does not have liability insurance, which poses as a potential health, safety or personal rights risk to children in care.
POC Due Date: 07/26/2023
Plan of Correction
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LPA provided Licensee with the LIC 311D and a blank LIC 282 form. Licensee said that she will have all daycare parents complete, date and sign this form. Licensee said that she will provide copies of these completed, dated and signed forms to LPA no later than 07/26/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
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