D D D D
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY DATE :
March 20, 2013
NOTIFICATION OF INCOMPLETE APPLICATION
FAC ILITY NAME:
As-Safa lnstitute/As-Safa Academy FACILITY FILE NUMBER:
43441 3125
lZJ
D
This incomplete application package is being returned to you. Items in Section A and B must be properly completed and submitted as a total package. Your application for a license remains incomplete as we have not received the items checked below. Please forward the reauested information within 30 days, or bring the information to the face-to-face interview scheduled on - - - - - - - - - - - - -- If this information is not received, your application will be considered withdrawn.
SECTION A -
D
D
LICENSING FORMS
A1 .
Application for Facility License {LIC 200 or LIC 200A)
A2 .
Applicant Information (LIC 215) For: NAME OF PERSON(S)
D
[Z]
D D D D D D D D D
A3 .
Designation of Administrative Responsibility {LIC 308)
A4.
Administrative Organization (LIC 309)
AS .
Affidavit Regarding ClienUResident Cash Resources {LIC 400)
A6.
Estimated Monthly Operating Budget (LIC 401)
A7.
Surety Bond (LIC 402)
A8.
Financial Statement {LIC 403)
A9.
Financial Information Release and Verification (LIC 404)
A10. Budget Information (LIC 420) A11. Personnel Report (LIC 500) A12. Personnel Record (LIC 501)
D
[Z]
D D D D D D D D D D D
A13. Health Screening Report- Facility Personnel {LIC 503) For: NAME OF PERSON
D
SECTION B- SUPPORTIVE DOCUMENTS
[Z]
B1 .
Partnership AgreemenUArticles of Incorporation
B2.
Verification of Administrator/Director Qualifications
B3.
Verification Social Worker Qualifications
B4.
Job Description - each position
B5.
Personnel Policies
B6.
lnservice Training for Staff
B7.
Facility Program Description
B8.
Rules of Discipline
B9.
Admission Policies
B10. Sample Menu B11 . List of Indoor/Outdoor Play Equipment and Inventory of Furniture B12. Control of Property B13. Bacteriological Analysis of Private Water Supply {When Water for Human consumption is from a Private Source).
Other
1. No proof of the applicant attended Application Orientation.
A14. Emergency Disaster Plan {LIC 610 or LIC 610A)
2. The director must have the ECE coursed units.
[Z]
A15. Facility Sketch (LIC 999)
3. Other Incomplete documents, please see the sUckers Inside the documents
D
A16. Local Fire Inspection Authority Information (LIC 9054)
The Application Fee Is Non-Refundable
LICENSING EVALUATOR'S SIGNATURE
PHONE NUMBER
( LIC 184 (5100) (PUBLIC)
406
)
3~321
STATE OF CALIFORNIA- HEALTH AN D HUMAN SERVICES AGENCY
CALIFORN IA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION
FACILITY EVALUATION REPORT
CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131
FACILITY NAME: AS-SAF A ACADEMY PRESCHOOL ADMIN ISTRATOR :ALI , HAJERA ADDRESS: 4250 LATIMER AVENUE CITY: SAN JOSE STATE :CA 24 CAPAC ITY : CENSUS: O UNANNOUNC ED TYPE OF VISIT : Prelicensing MET WITH : Hajera Ali
1 2 3 4 5 6
FACILITY NUMBER: FACILITY TY PE: TELEPHONE : ZIP CODE : DATE: TIME BEGAN : TIME COMPLETED:
434413125 850 (408) 265-3590 95130 07/03/2013 08:50AM 10:30 AM
NARRATIVE Licensing Program Analyst (LPA) Shan Tan conducted a second pre-licensing visit to the facility to ch eck the stove cover. Applicant Hajera Ali stated that after she has consulted with the fire inspector, she decided to order a metal stove topper to cover the stove . Today, LPA observed that Ali has a temporary wood board on the top of the stove. According to the fire inspector request , Ali has put a microwave on the top of the cover and has 4 plastic stove knob covers on the knobs . Ali stated that after she has received the metal stove topper, she will send pictures to LPA.
7 8 LPA has also discussed the director requirements with Applicant. Applicant has enrolled in the Child family 9 and Society course at Ashford University. The applicant will attend the class from July 16, 2013 to the end of 10 August. LPA has received the confirmation of the enrollment from applicant and the school through email. 11 Today , applicant has also submitted her request for exception to al low her to be the program director to LPA. 12 Applicant has brought a step on tight-fitting lid garbage can . LPA observed that the garbage can is placing 13 14 near the classroom counter. 15 16 During today's visit, LPA has obtained a copy of the MTS Enterprises , LLC. invoice for ordering the metal 17 stove topper. 18 19 Upon the re ceipt of app licant's crimin al clearance, licensure of 24 ch ildren will be rec o mmended for 20 approval. 21 22 23 24 25 TEL EPH ONE: (408) 324-2148 SUPERVISOR'S NAME : Sandy Knight LICENSING EVALUATOR NAME: Shan Tan
TELEPH ONE: (408) 334-8321
LICENSING EVALUATOR SI GNATURE: DATE : 07/03/2013
I acknowledge receipt of this form an d und ersta nd my licensing appeal righ ts as expl ained and received. FACILITY REPRESENTATIVE SIG NATURE : DATE: 07/03/2013
This rep o rt must be available at Chi ld Care and Group Home facilities f o r publi c review for 3 years . Pa ge: 1 o f 1
LIC809 (FAS) - (06/04)
..
STATE OF CALIFORNIA · HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION
FACILITY EVALUATION REPORT
CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131 .
FACILITY NAME: AS-SAF A INSTITUTE/AS-SAF A ACADEMY ADMINISTRATOR: All, HAJERA ADDRESS: 4250 LATIMER AVENUE STATE:CA CITY: SAN JOSE CENSUS:O CAPACITY: 24 UNANNOUNCED TYPE OF VISIT: Prelicensing MET WITH: Hajera Ali
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
FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED:
434413125 850 (408) 265-3590 95130 06/2 7/2013 10:45 AM 01 :55PM
NARRATIVE Licensing Program Analyst (LPA) Shan Tan met with applicant Hajera Ali for a pre-licensing. Applicant is requesting for a capacity of 24 preschool children . This facility is located at Moreland School District campus . This preschool is going to use one of the classrooms in the Admin Building area , which is leased by the As Safa Institute Limited Liability Company. The school operation hours will be Monday-Thursday from 8 am to 3:30 pm , Friday 8 am to 12:30 pm. LPA toured the facility inside and out. Facility measurements are as follows: INDOOR MEASUREMENTS: Classroom : 28.415 x 31 = 880.865 minus 36.822 (encumbered space)= 844.043 TOTAL INDOOR SPACE: 844.043 sq. ft. divided by 35 = 24 children. LPA observed that the lighting is adequate. Indoor temperature is controlled by central heating and air conditioning. There are 29 chairs, 4 tables and 24 napping mats in the facility. There are 24 cubbies available for children to put their belongings in the hallway between the classroom and the school main office. Applicant stated that children will bring their own water bottles and they can refill their bottles from the counter sink. The applicant stated that the children also bring their own lunch and snacks to the school. LPA observed that the classroom counter includes a refrigerator, a microwave, a stove , a dishwasher and a sink with hot and cold running water. LPA observed that First Aid kit is available in the upper cabinet. Applicant stated that medication is administered in the center and the medication is stored in the upper cabinet too . The sick children will be isolated in a separate space in the classroom and that isolation equipment is provided. The preschool children are going to share bathrooms with the As Safa Academy Elementary School which is located in the hallway to the main office. LPA observed 2 toilets and 2 sinks (2x15=30) in the bathroom. A request for a waiver for sharing the bathrooms with the elementary school children has been submitted to the licensing office with the application document. The staff has separate bathroom in the same building and the school campus . Applicant understood that a sick child has to use the staff bathroom. Analyst observed that all the cleaning supplies and hazardous are placed on the top of the refrigerator inaccessible to children .
Facility evaluation report is continued on the next page: SUPERVISOR'S NAME: Sandy Knight
TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Shan Tan
TELEPHONE: (408) 334-8321
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2013
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE : 06/27/2013
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 2
STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION
FACILITY EVALUATION REPORT (Cont)
CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131
FACILITY NAME: AS-SAF A INSTITUTE/AS-SAFA ACADEMY
FACILITY NUMBER: 434413125 VISIT DATE: 06/27/2013
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
Facility evaluation report is continued from the previous page: OUTDOOR MEASUREMENTS: Playground: 165 x 71 .664 = 11824.560 minus 87 .800 (encumbered space)= 11736.760 TOTAL OUTDOOR SPACE: 11736.760 sq. ft. divided by 75 = 156 children. The preschool is going to share the outdoor play area with other programs in the campus. The area is fenced and is next to the Admin . Building . There was play structure in the play area. There are adequate rubber tiles for resilient material under the play structure .. The shade is provided by trees and building overhangs. A request a waiver to share the playground with other program in the campus has been submitted to the licensing office included in the application documents. During the visit, the followings were discussed : Isolation of sick children ; supervision of children ; teacher-child ratio; requirements for reporting suspected child abuse ; unusual incident/injuries; children's personal rights and no corporal punishment. LPA also reminded of the applicable Civil Penalty per person for those adults who have not received fingerprint clearances, are not associated to the license, come into contact with and or provide care and those who provide supervision to the children . Forms and Title 22 Regulations can be obtained through the internet at www.ccld.ca.gov. A copy of child care parents notification Assembly Bill 633 and Acknowledgement of Receipt of Licensing Reports (LIC 9224) form were provided and explained . Zero Tolerance with $150 civil penalty also explained to applicant. LPA has also discussed the director's qualification with the applicant. Applicant has completed a teacher credentialing program from the State of Massachusetts and holds a BA in Education & Child Study. Applicant has been the principal of the As Safa Academy Elementary School for 6 years . Applicant needs to enroll in the Child community and family course and submit a request for an exception to be the center director to the licensing office. Fire clearance has been granted by the Fire Marshal on 6/12/13. Applicant understood that before the license can be recommended to be approval, the following documents are needed: 1.A request for an exception for director. 2.Criminal records clearances for the staff members. A second pre-licensing visit to inspect the cover of the unused stove was scheduled on 7/3 .
SUPERVISOR'S NAME: Sandy Knight
TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Shan Tan
TELEPHONE: {408) 334-8321
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2013
I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE:
" LIC809 (FAS)- (06/04)
DATE: 06/27/2013
Page: 2 of 2
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY
FACILITY VISIT CHECKLIST CHILD CARE CENTERS AND INFANT CENTERS Review facility file prior to visit. Check to see that the following information has been updated , if required, and contained in the file . I A~ cate the date the i~rma~h wa;z_bmitted to the licensing agency in the space provided for each item requested. S:I!J-F.A -A-oJUJ!o~A.(, DATE DATE LICENSE ANNIVERSARY DATE O ON FILE REQUESTED RECEIVED ~44l3to
Health Screen ing Report- Facility Personnel (LIC 503)
'\ //
Daily Activity Schedule
/
Fire Clearance (consistent with terms and limitations of license)
k/.31/t3
~-
Bacteriological Analysis of Private Water Supply (if applicable)
I
f
c6 /olr (
,/
License Fee Received NOTES AND COMMENTS
Posting : License, Emergency Plan , Earthquake, Parents' Rights Poster, Personal Rights , Menus, Activity List, Car seat Law Waiver?
Sign In/Out?
Indoor: Heating/LightingNentilation? Bathrooms(working/clean)? 1st Aid Kit?
Drinking Water? Toys/Carpet( clean)?
Toxic Materials? Mats/Cots(good condition)?
Isolation of Sick Children?
Kitchen (w/hot & cold water)?
Medication? Food Pre/Plan/Dishes? Solid Wasted Containers?
Outdoor: Fenced?
Bodies of Water?
Play equipment?
Sufficient Resilient?
Infant: Changing Table?
Needs & Services Plan?
Daily Log( diaper change , feeding)?
Bottles/Food Stored & Labeled Correctly? Care & Supervision? LIC9118 (11 /03)
*Other verifying documents may be substituted for these LIC forms
I
STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY DATE :
March 20, 2013
NOTIFICATION OF INCOMPLETE APPLICATION
FAC ILITY NAME:
As-Safa lnstitute/As-Safa Academy FACILITY FILE NUMBER:
43441 3125
lZJ
D
This incomplete application package is being returned to you. Items in Section A and B must be properly completed and submitted as a total package. Your application for a license remains incomplete as we have not received the items checked below. Please forward the reauested information within 30 days, or bring the information to the face-to-face interview scheduled on - - - - - - - - - - - - -- If this information is not received, your application will be considered withdrawn.
SECTION A -
D
D
LICENSING FORMS
A1 .
Application for Facility License {LIC 200 or LIC 200A)
A2 .
Applicant Information (LIC 215) For: NAME OF PERSON(S)
D
[Z]
D D D D D D D D D
A3 .
Designation of Administrative Responsibility {LIC 308)
A4.
Administrative Organization (LIC 309)
AS .
Affidavit Regarding ClienUResident Cash Resources {LIC 400)
A6.
Estimated Monthly Operating Budget (LIC 401)
A7.
Surety Bond (LIC 402)
A8.
Financial Statement {LIC 403)
A9.
Financial Information Release and Verification (LIC 404)
A10. Budget Information (LIC 420) A11. Personnel Report (LIC 500) A12. Personnel Record (LIC 501)
D
[Z]
D D D D D D D D D D D
A13. Health Screening Report- Facility Personnel {LIC 503) For: NAME OF PERSON
D
SECTION B- SUPPORTIVE DOCUMENTS
[Z]
B1 .
Partnership AgreemenUArticles of Incorporation
B2.
Verification of Administrator/Director Qualifications
B3.
Verification Social Worker Qualifications
B4.
Job Description - each position
B5.
Personnel Policies
B6.
lnservice Training for Staff
B7.
Facility Program Description
B8.
Rules of Discipline
B9.
Admission Policies
B10. Sample Menu B11 . List of Indoor/Outdoor Play Equipment and Inventory of Furniture B12. Control of Property B13. Bacteriological Analysis of Private Water Supply {When Water for Human consumption is from a Private Source).
Other
1. No proof of the applicant attended Application Orientation.
A14. Emergency Disaster Plan {LIC 610 or LIC 610A)
2. The director must have the ECE coursed units.
[Z]
A15. Facility Sketch (LIC 999)
3. Other Incomplete documents, please see the sUckers Inside the documents
D
A16. Local Fire Inspection Authority Information (LIC 9054)
The Application Fee Is Non-Refundable
LICENSING EVALUATOR'S SIGNATURE
PHONE NUMBER
( LIC 184 (5100) (PUBLIC)
406
)
3~321
STATE OF CALIFORNIA- HEALTH AN D HUMAN SERVICES AGENCY
CALIFORN IA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION
FACILITY EVALUATION REPORT
CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131
FACILITY NAME: AS-SAF A ACADEMY PRESCHOOL ADMIN ISTRATOR :ALI , HAJERA ADDRESS: 4250 LATIMER AVENUE CITY: SAN JOSE STATE :CA 24 CAPAC ITY : CENSUS: O UNANNOUNC ED TYPE OF VISIT : Prelicensing MET WITH : Hajera Ali
1 2 3 4 5 6
FACILITY NUMBER: FACILITY TY PE: TELEPHONE : ZIP CODE : DATE: TIME BEGAN : TIME COMPLETED:
434413125 850 (408) 265-3590 95130 07/03/2013 08:50AM 10:30 AM
NARRATIVE Licensing Program Analyst (LPA) Shan Tan conducted a second pre-licensing visit to the facility to ch eck the stove cover. Applicant Hajera Ali stated that after she has consulted with the fire inspector, she decided to order a metal stove topper to cover the stove . Today, LPA observed that Ali has a temporary wood board on the top of the stove. According to the fire inspector request , Ali has put a microwave on the top of the cover and has 4 plastic stove knob covers on the knobs . Ali stated that after she has received the metal stove topper, she will send pictures to LPA.
7 8 LPA has also discussed the director requirements with Applicant. Applicant has enrolled in the Child family 9 and Society course at Ashford University. The applicant will attend the class from July 16, 2013 to the end of 10 August. LPA has received the confirmation of the enrollment from applicant and the school through email. 11 Today , applicant has also submitted her request for exception to al low her to be the program director to LPA. 12 Applicant has brought a step on tight-fitting lid garbage can . LPA observed that the garbage can is placing 13 14 near the classroom counter. 15 16 During today's visit, LPA has obtained a copy of the MTS Enterprises , LLC. invoice for ordering the metal 17 stove topper. 18 19 Upon the re ceipt of app licant's crimin al clearance, licensure of 24 ch ildren will be rec o mmended for 20 approval. 21 22 23 24 25 TEL EPH ONE: (408) 324-2148 SUPERVISOR'S NAME : Sandy Knight LICENSING EVALUATOR NAME: Shan Tan
TELEPH ONE: (408) 334-8321
LICENSING EVALUATOR SI GNATURE: DATE : 07/03/2013
I acknowledge receipt of this form an d und ersta nd my licensing appeal righ ts as expl ained and received. FACILITY REPRESENTATIVE SIG NATURE : DATE: 07/03/2013
This rep o rt must be available at Chi ld Care and Group Home facilities f o r publi c review for 3 years . Pa ge: 1 o f 1
LIC809 (FAS) - (06/04)
..
STATE OF CALIFORNIA · HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION
FACILITY EVALUATION REPORT
CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131 .
FACILITY NAME: AS-SAF A INSTITUTE/AS-SAF A ACADEMY ADMINISTRATOR: All, HAJERA ADDRESS: 4250 LATIMER AVENUE STATE:CA CITY: SAN JOSE CENSUS:O CAPACITY: 24 UNANNOUNCED TYPE OF VISIT: Prelicensing MET WITH: Hajera Ali
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
FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED:
434413125 850 (408) 265-3590 95130 06/2 7/2013 10:45 AM 01 :55PM
NARRATIVE Licensing Program Analyst (LPA) Shan Tan met with applicant Hajera Ali for a pre-licensing. Applicant is requesting for a capacity of 24 preschool children . This facility is located at Moreland School District campus . This preschool is going to use one of the classrooms in the Admin Building area , which is leased by the As Safa Institute Limited Liability Company. The school operation hours will be Monday-Thursday from 8 am to 3:30 pm , Friday 8 am to 12:30 pm. LPA toured the facility inside and out. Facility measurements are as follows: INDOOR MEASUREMENTS: Classroom : 28.415 x 31 = 880.865 minus 36.822 (encumbered space)= 844.043 TOTAL INDOOR SPACE: 844.043 sq. ft. divided by 35 = 24 children. LPA observed that the lighting is adequate. Indoor temperature is controlled by central heating and air conditioning. There are 29 chairs, 4 tables and 24 napping mats in the facility. There are 24 cubbies available for children to put their belongings in the hallway between the classroom and the school main office. Applicant stated that children will bring their own water bottles and they can refill their bottles from the counter sink. The applicant stated that the children also bring their own lunch and snacks to the school. LPA observed that the classroom counter includes a refrigerator, a microwave, a stove , a dishwasher and a sink with hot and cold running water. LPA observed that First Aid kit is available in the upper cabinet. Applicant stated that medication is administered in the center and the medication is stored in the upper cabinet too . The sick children will be isolated in a separate space in the classroom and that isolation equipment is provided. The preschool children are going to share bathrooms with the As Safa Academy Elementary School which is located in the hallway to the main office. LPA observed 2 toilets and 2 sinks (2x15=30) in the bathroom. A request for a waiver for sharing the bathrooms with the elementary school children has been submitted to the licensing office with the application document. The staff has separate bathroom in the same building and the school campus . Applicant understood that a sick child has to use the staff bathroom. Analyst observed that all the cleaning supplies and hazardous are placed on the top of the refrigerator inaccessible to children .
Facility evaluation report is continued on the next page: SUPERVISOR'S NAME: Sandy Knight
TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Shan Tan
TELEPHONE: (408) 334-8321
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2013
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE : 06/27/2013
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 2
STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION
FACILITY EVALUATION REPORT (Cont)
CCLD Regional Office, 2580 N FIRST STREET, STE. 300 SAN JOSE, CA 95131
FACILITY NAME: AS-SAF A INSTITUTE/AS-SAFA ACADEMY
FACILITY NUMBER: 434413125 VISIT DATE: 06/27/2013
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
Facility evaluation report is continued from the previous page: OUTDOOR MEASUREMENTS: Playground: 165 x 71 .664 = 11824.560 minus 87 .800 (encumbered space)= 11736.760 TOTAL OUTDOOR SPACE: 11736.760 sq. ft. divided by 75 = 156 children. The preschool is going to share the outdoor play area with other programs in the campus. The area is fenced and is next to the Admin . Building . There was play structure in the play area. There are adequate rubber tiles for resilient material under the play structure .. The shade is provided by trees and building overhangs. A request a waiver to share the playground with other program in the campus has been submitted to the licensing office included in the application documents. During the visit, the followings were discussed : Isolation of sick children ; supervision of children ; teacher-child ratio; requirements for reporting suspected child abuse ; unusual incident/injuries; children's personal rights and no corporal punishment. LPA also reminded of the applicable Civil Penalty per person for those adults who have not received fingerprint clearances, are not associated to the license, come into contact with and or provide care and those who provide supervision to the children . Forms and Title 22 Regulations can be obtained through the internet at www.ccld.ca.gov. A copy of child care parents notification Assembly Bill 633 and Acknowledgement of Receipt of Licensing Reports (LIC 9224) form were provided and explained . Zero Tolerance with $150 civil penalty also explained to applicant. LPA has also discussed the director's qualification with the applicant. Applicant has completed a teacher credentialing program from the State of Massachusetts and holds a BA in Education & Child Study. Applicant has been the principal of the As Safa Academy Elementary School for 6 years . Applicant needs to enroll in the Child community and family course and submit a request for an exception to be the center director to the licensing office. Fire clearance has been granted by the Fire Marshal on 6/12/13. Applicant understood that before the license can be recommended to be approval, the following documents are needed: 1.A request for an exception for director. 2.Criminal records clearances for the staff members. A second pre-licensing visit to inspect the cover of the unused stove was scheduled on 7/3 .
SUPERVISOR'S NAME: Sandy Knight
TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Shan Tan
TELEPHONE: {408) 334-8321
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2013
I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE:
" LIC809 (FAS)- (06/04)
DATE: 06/27/2013
Page: 2 of 2
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY
FACILITY VISIT CHECKLIST CHILD CARE CENTERS AND INFANT CENTERS Review facility file prior to visit. Check to see that the following information has been updated , if required, and contained in the file . I A~ cate the date the i~rma~h wa;z_bmitted to the licensing agency in the space provided for each item requested. S:I!J-F.A -A-oJUJ!o~A.(, DATE DATE LICENSE ANNIVERSARY DATE O ON FILE REQUESTED RECEIVED ~44l3to
Health Screen ing Report- Facility Personnel (LIC 503)
'\ //
Daily Activity Schedule
/
Fire Clearance (consistent with terms and limitations of license)
k/.31/t3
~-
Bacteriological Analysis of Private Water Supply (if applicable)
I
f
c6 /olr (
,/
License Fee Received NOTES AND COMMENTS
Posting : License, Emergency Plan , Earthquake, Parents' Rights Poster, Personal Rights , Menus, Activity List, Car seat Law Waiver?
Sign In/Out?
Indoor: Heating/LightingNentilation? Bathrooms(working/clean)? 1st Aid Kit?
Drinking Water? Toys/Carpet( clean)?
Toxic Materials? Mats/Cots(good condition)?
Isolation of Sick Children?
Kitchen (w/hot & cold water)?
Medication? Food Pre/Plan/Dishes? Solid Wasted Containers?
Outdoor: Fenced?
Bodies of Water?
Play equipment?
Sufficient Resilient?
Infant: Changing Table?
Needs & Services Plan?
Daily Log( diaper change , feeding)?
Bottles/Food Stored & Labeled Correctly? Care & Supervision? LIC9118 (11 /03)
*Other verifying documents may be substituted for these LIC forms
I
