STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Of?ce. 7575 METROPOLITAN DR., STE 110 SAN DIEGO. CA 92108 FACILITY NAME: SEDIQI, KATRIEN FAMILY CHILD CARE FACILITY NUMBER: 376624322 ADMINISTRATOR: KATRIEN SEDIQI FACILITY TYPE: 810 ADDRESS: 17472 MATINAL ROAD TELEPHONE: (760) 670-9203 CITY: SAN DIEGO STATE: CA ZIP CODE: 92127 CAPACITY: 8 CENSUS: 0 DATE: 11/14/2013 TYPE OF VISIT: Prelicensing ANNOUNCED TIME 10:10 AM MET WITH: Katrien Sediqi TIME COMPLETED: 11:30 AM NARRATIVE 25 NAME: Carol August LICENSING EVALUATOR NAME: Tulam Vu LPA Tulam Vu made an announced pre-licensing visit for the purpose of a change of location. Met with applicant Katrien Sediqi. All adults living in the home have received criminal record and TB clearances. Mrs.Sediqi has completed the Preventative Health training including pediatric CPR ?rst aid certi?cations valid through 12/22/2014. This single story, 4-bedroom, 2-bath home was toured. The following areas will be used for day care: living room, dining room, kitchen, family room (child care room), hallway bathroom and fenced back yard. Off-limit areas include the garage and all 4 bedrooms which are made inaccessible to children through locks. All hazardous items were latched. Lower cabinets in the kitchen and bathroom have safety latches or do not contain any hazardous items. There is an operational smoke alarm and ?re extinguisher maintained in the home. The home has electrical outlet covers throughout the day care areas. Fire place is screened. There are toys and equipment for children's use. Mrs. Sediqi stated there are no weapons or bodies of water present on the premises. Rental agreement was veri?ed. All required forms are posted in a prominent area. LPA reviewed the following: required departmental documents, regulation highlights, capacity limitations, care supervision, clearances required for all adults prior to working and/or residing in the home, disaster drills every 6 months, unusual incidents, mandated reporting, Assembly Bill 633, SIDS, Shaken Baby and Megan's law, AB 2084 Healthy Beverages in Child Care. new car safety seat law. Mrs. Sediqi is reminded that corporal punishment, smoking. baby walkers, exersaucers, jumpers and bouncy/rocker seats are not be permitted during day care hours. Licensing Website: A small license can be granted effective 11/14/2013. The maximum capacity: 6 children with no more than 3 infants (0-24 months) g4 infants only. 8 children with no more than 2 infants, 1 child in kindergarten or element school and 1 child at least age 6 including licensee's children under age 10 with landlord consent. TELEPHONE: (619) 767-2250 TELEPHONE: (619) 767-2238 LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2013 Had/(tan This report must be available at Child Care and Group Home facilities for public review for 3 years. Page: 1 of 1 means (PAS) - {06/04} STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Of?ce, 7575 METROPOLITAN DR., STE 110 SAN DIEGO, CA 92108 FACILITY NAME: SEDIQI, KATRIEN FAMILY CHILD CARE FACILITY NUMBER: 376624322 ADMINISTRATOR: KATRIEN SEDIQI FACILITY TYPE: 810 ADDRESS: 17472 MATINAL ROAD TELEPHONE: (760) 670?9203 CITY: SAN DIEGO STATE: CA ZIP CODE: 92127 CAPACITY: 8 CENSUS: 4 DATE: TYPE OF VISIT: Case Management UNANNOUNCED TIME 01:25 PM MET WITH: Katrien Sediqi TIME COMPLETED: 03:15 PM NARRATIVE Licensing Program Analyst (LPA) Tulam Vu made an unannounced case management visit for the purpose of an increase in capacity. Met with Licensee Katrien Sediqi who was on site with 4 infants. A review of staff records on 8/20/14 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances. Licensee and her spouse have current CPR ?rst aid certi?cations valid through 12122114 This single story, 4 bedrooms. 2 bathrooms home was inspected. The following areas are used for day care: living room, dining room, kitchen. famin room, hallway bathroom and fenced play yard. Off-limit areas include the garage and all 4 bedrooms which are made inaccessible to children through door locks. There are ample space, toys, play equipment and napping equipment for an increase in capacity. The home is clean. orderly and has adequate heating and ventilation. There is an operational smoke alarm and ?re extinguisher in the home. All hazardous items are stored behind latched cabinets. Licensee stated there are no weapons or bodies of water present on the premises. Children's records were reviewed. The last ?re drill was conducted on 7H 5/14. All required forms are posted. Fire clearance for 14 children was granted on 8/6/14. LPA reviewed the following with Licensee: Criminal background clearance requirements and TB test for all adults/helpers prior to working and/or residing in the home. Care supervision, unusual incidents, SIDS, Shaken Baby child abuse reporter responsibilities were all reviewed. The following de?ciencies cited for correction per CCR, Title 22, Division 12. Chapter 1 regulations for Family Child Care Home. Refer to the next page 809D for de?ciency citations. Provided appeal rights. A large license will be granted once all corrections have been completed. NAME: Carol August TELEPHONE: (619) 767-2250 LICENSING EVALUATOR NAME: Tulam Vu TELEPHONE: (619) 767-2238 LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2014 A.- I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: Pmawmm This report must be available at Child Care and Group Home facilities for public review for 3 years. LICSOQ (FAS) - (05104] Page: 1 of 2 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont) CCLD Regional Of?ce. 7575 METROPOLITAN DR.. STE 110 SAN DIEGO, CA 92108 FACILITY NAME: SEDIQI, KATRIEN FAMILY CHILD CARE 376624322 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 08/20l2014 De?ciency Type POC Due Date! DEFICIENCIES PLAN OF Section Number 1 102417(g)(10) Operation of a Famin Child Care I Licensee corrected the de?ciency during the visit Type 2 Home. A baby walker is not permitted on the 2 by removing the baby rocker to an off limit area and 0800,2014 3 premises of a famin child care home in accordance 3 agreed not to use prohibited items (baby walkers, Section Cited 4 with Health and Safety Code Sections 1596.846(b) 4 exersaucers. jumpers and bouncerlrockerdaycare. 0 4 (9X - LPA observed a baby rocker in the daycare area. 1 102417(g)(8) Operation of a Family Child Care 1 Licensee stated a current roster form LIC 9040 will Type 2 Home. All homes shall have a Current roster of the 2 be submitted to Licensing by 8l25i14. 08252014 3 Chi'dren- 3 Section Cited 2 ?aicensee did not have a roster of the children in 102417(g)(8) 5 5 7 7 1 102417(g)(7) Operation of a Family Child Care 1 Licensee will obtain forms LIC 700 8. LIC 62? for Type 2 Home 2 Child Copies will be sent to Licensing by 3 - Child #1 (refer to LIC 811) did not have the 3 ar25r14. 081252014 Section Cited 4 emergency information form and the parent's 4 102417 5 authorization for the licensee to consent to 5 (9X7) 3 emergency medical care on ?le. 2 1 102419(c) Admission Procedures and Parental and 1 Licensee will provide form LIC 995E to the child's Type 2 Authorized Representative's Rights - 2 parents and submit a copy LIC 995 to Licensing by 3 Child #1 did not the the parent's rights form LIC 3 8r25/14. 089512014 4 4 Section Cited 5 995 on ?le' 5 102419(c) 5 5 7 7 Failure to correct the cited de?ciency?es), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. NAME: Carol August TELEPHONE: (619) 767-2250 LICENSING EVALUATOR NAME: Tulam Vu TELEPHONE: (619) 767-2238 LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2014 7 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2014 Llcaos (FAS) 4:15:04) Page: 2 or 2 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT Regional Office, 7575 METROPOLITAN DR., STE 110 SAN DIEGO. CA 92108 FACILITY NAME: SEDIQI, KATRIEN FAMILY CHILD CARE FACILITY NUMBER: 376624322 ADMINISTRATOR: KATRIEN SEDIQI FACILITY TYPE: 810 ADDRESS: 17472 MATINAL ROAD TELEPHONE: (760) 670?9203 CITY: SAN DIEGO STATE: CA ZIP CODE: 92127 CAPACITY: 8 CENSUS: 4 DATE: 08/29/2014 TYPE OF VISIT: POC UNANNOUNCED 1225 PM MET WITH: Katrien Sediqi TIME COMPLETED: 01 :20 PM NARRATIVE 1 Unannounced Plan of Correction visit made by LPA Tulam Vu to follow up on de?ciencies cited during a case 2 management visit. Met with licensee Katrien Sediqi who was on site with 4 infants. Also present was 3 licensee's husband Abdullah Sediqi. Licensee requested one of the bedrooms (room use for napping. 4 LPA inspected the bedroom and determined to be safe and clean. 5 6 De?ciencies cited on 8/20/14 have been corrected as follows: 7 8 1. Licensee now has a current roster of children in care. A copy of the roster was given to the LPA. 9 2. Children's records were reviewed. Child #1 now has all the required papen/vork on ?le. Licensee agreed 10 to maintain children's records including immunization blue cards for all children enrolled in the facility. 11 3. Licensee no longer has the baby rocker in the facility. 12 4. Required papenNork for new helper Hafiza Hafizi was also reviewed during the visit. 14 All de?ciencies cited on 8/20/14 have been cleared. 16 A license for 14 children can be granted effective this date (8/29/14). 18 The maximum number of children for whom care shall be provided when there is an assistant provider in the 19 home; including children under age 10 who live in the licensee?s home and the assistant provider?s children 20 under age 10. shall be either: Twelve (12) children with no more than four of whom may be infants 21 Fourteen (14) children, at least two of the children are at least six years of age and no more than three 22 infants. 23 24 25 NAME: Carol August TELEPHONE: (619) 767-2250 LICENSING EVALUATOR NAME: Tulam Vu TELEPHONE: (619) 767-2238 LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2014 7' I acknowledge receipt of this form and understand my licensing appeal rights as exptained and received. FACILITY REPRESENTATIVE SIG NATURE: 4.12} This report must be available at Child Care and Group Home facilities for public review for 3 years. Lloaos - {05/04} Page: 1 of1