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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566215915
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:29:59 PM

Document Has Been Signed on 05/16/2023 03:29 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:FAROOK FCC AKA SAFIA'S HOME DAYCAREFACILITY NUMBER:
566215915
ADMINISTRATOR:FATHIMA SAFIA FAROOKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 256-7872
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
05/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:FATHIMA SAFIA FAROOKTIME COMPLETED:
03:45 PM
NARRATIVE
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On May 16, 2023 Licensing Program Analyst's (LPA's) Susana Martinez and Daniel Venegas conducted an unannounced case management-other inspection. LPA's met with the licensee Fathima Safia Farook and advised her of the purpose for the inspection. Together with the licensee, LPA's toured the home. At the time of the inspection there were 9 children and 2 adults present.

On 3/23/2023 LPA Martinez conducted an unannounced inspection to initiate a complaint regarding Neglect/Lack of Supervision. At the time of the inspection there were 11 children present along with licensee. Licensee stated that her assistant had recently called out sick. There were no other adults in the home at that time.

LPA Martinez conducted record review and concluded that Licensee was over ratio. Licensee was caring for 4 infants and 7 other children who were under the age of 6 years old.

The following CCR, Title 22, Division 12 regulation was discussed: 102416.5 Staffing Ratio and Capacity

One type A deficiency was cited during today's inspection. Please refer to the LIC809D for documentation of deficiencies cited.

A copy of this report must be provided to the authorized representatives of all currently enrolled children and must also be provided to newly enrolled children for the next 12 months. The report shall be provided no later than the next business day or the next day the child is in care.

Continued on 809-C

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: FAROOK FCC AKA SAFIA'S HOME DAYCARE
FACILITY NUMBER: 566215915
VISIT DATE: 05/16/2023
NARRATIVE
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The ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) shall be signed and kept in each of the children’s records. Web site address to obtain forms, review quarterly updates, review Title 22 & Health & Safety Codes is: https://www.cdss.ca.gov/inforesources/child-care-licensing

Copies of this report must be posted for 30 days in a visible location for the authorized representatives of children. Notice of Site Visit has been posted (LIC9213). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Licensee has also been invited for an in-office informal conference which will be scheduled at a later time.

Exit interview conducted with Licensee Safia Farook. A copy of the Appeal Rights (LIC 9058 FAS 01/16) were given and explained. Licensee’s signature on this form acknowledges receipt of these rights.

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2023 03:29 PM - It Cannot Be Edited


Created By: Susana Martinez On 05/16/2023 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: FAROOK FCC AKA SAFIA'S HOME DAYCARE
FACILITY NUMBER: 566215915

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2023
Section Cited
CCR
102416.5(e)

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102416.5 Staffing Ratio and Capacity (e)If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). This requirement is not met as evidenced by:
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Licensee must submit a written plan on how she plans on preventing being out of ratio to CCL by mail, text, or email to susana.martinez@dss.ca.gov. Licensee is also to watch videos regarding ratio on https://ccld.childcarevideos.org/ website. Licensee will be requested to attend an informal conference which will be scheduled at a later date.
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Based on LPAs observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 counts as LPA observed licensee being out of ratio, which posed an immediate 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.
SUPERVISOR'S NAME:George Mingle
LICENSING EVALUATOR NAME:Susana Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023


LIC809 (FAS) - (06/04)
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