Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422344
Report Date: 09/18/2015 12:00:00 AM
Date Signed 09/18/2015 01:03:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:HABIB, RAQUELFACILITY NUMBER:
013422344
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
09/18/2015
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Raquel and Syed HabibTIME COMPLETED:
01:10 PM
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This is an unannounced Increase in Capacity visit conducted today by Sherelle Johnson, Licensing Program Analyst. LPA met with licensee, Raquel Habib, and her husband, Syed Habib who guided analyst on a tour of the facility. Both adults have cleared fingerprint clearances. All areas identified on the facility sketch were inspected. There were 5 day care children present. Family members residing at facility are 2 adults and 2 children (14 and 17). Licensee is reminded that all adults 18 years of age and old must have a fingerprint clearance before being in the presence of day care children.

The home is a single story home. The home consists of 3 bedrooms, 3 bathrooms, kitchen, living room, 2 family rooms, laundry room, garage and backyard. The home is neat and clean with central heating and ventilation for safety and comfort.

The OFF LIMIT AREAS are all bedrooms, family room #2, kitchen, bathroom next to the kitchen, bathroom in the family room #2, sectioned off area of the backyard around the outdoor play space, laundry room and garage which will be inaccessible by closed and/or locked doors, safety gates and visual supervision.

The AREAS USED are the living room, family room #1 next to the living room, bathroom in the hallway where the bedrooms are located and a sectioned off portion of the backyard outside of family room #2. The ISOLATION AREA will be the right corner of the living room separated from the children in care. Outdoor play area will be a sectioned portion next to family room #2 and is fully fenced. The children will walk through family room #2 only to get to the outdoor play area and will be escorted through that room to that section portion. The outdoor play area is free from defects or dangerous conditions. There are ample age appropriate toys that are safe and appeared to be clean. There are no pools, hot tubs or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Sherelle JohnsonTELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2015
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HABIB, RAQUEL
FACILITY NUMBER: 013422344
VISIT DATE: 09/18/2015
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The home has a fully charged 2A10BC fire extinguisher, working smoke detector, carbon monoxide detector, working telephone, and fully stock First Aid Kit. The Licensee's Health and Safety training is completed and CPR and First Aid certificate is current and expires 07/12/2016.

LPA received an approved fire clearance signed 9/16/16 for an increase in capacity to 14 children from fire Marshall stating Fire and safety clearance granted for the home.

The request for an increase is approved effective 9/18/15. Exit interview conducted, notice of site visit posted. All reports shall be maintained for 3 years and available for review upon request.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Sherelle JohnsonTELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2015
LIC809 (FAS) - (06/04)
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