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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700151
Report Date: 08/20/2020
Date Signed: 08/20/2020 04:17:30 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:HASSANI, YALDAFACILITY NUMBER:
015700151
ADMINISTRATOR:HASSANI, YALDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 557-9723
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:14CENSUS: 0DATE:
08/20/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Yalda HassaniTIME COMPLETED:
04:14 PM
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***DUE TO THE COVID-19 SHELTER IN PLACE ORDER BY THE GOVERNOR OF CALIFORNIA, THIS PRE-LICENSING VISIT WAS DONE VIA TELE-VISIT***

On 8/20/2020, at 1:15pm Licensing Program Analyst (LPA) Jonathan Williams met with Applicant, Yalda Hassani, via video conferencing app "Whatsapp" for the purpose of conducting an announced prelicensing inspection for a change of location. Present during today's inspection was the Applicant only. The home was toured to conduct a health and safety inspection.

The facility is a two story home owned by the Applicant. The first floor consists of a living room #1, living room #2, kitchen, guest bedroom, converted garage, play room, bathroom, and backyard. The second story consists of three bedrooms and two bathrooms. The home is neat and clean. All toxins, hazardous materials, and cleaning compounds were observed to be made inaccessible to children throughout the inspection. Per Applicant, there are no firearms in the facility. The facility backyard was observed at 1:45pm to have an above-ground swimming pool which LPA observed to be surrounded by a fence at least five feet tall with a self-latching gate that opens outward. Due to poor internet connection interfering with the video feed, LPA was unable to clearly view the portion of the backyard behind the above-ground swimming pool. The remainder of the backyard was observed to be free of dangerous defects and conditions and was observed to be free of hazardous or age-inappropriate materials.

On-limit-areas: Living room #2, first floor bathroom, kitchen, guest bedroom, play room, converted garage, backyard.
Off-limit-areas: Living room #1, entire second floor.
Isolation room: Living room #2.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: HASSANI, YALDA
FACILITY NUMBER: 015700151
VISIT DATE: 08/20/2020
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The home was observed at 2:03pm to have a working smoke and carbon monoxide detector (combined) and a working telephone. The Applicant produced CPR and First Aid training certificate (issued on 8/24/2019) and produced proof of enrollment in Preventive Health & Safety training (scheduled for 10/17/2020). The Applicant has required Mandated Reporter Training certificates which LPA observed at 2:30pm to have been issued on 4/18/2019 (Child Care Providers) and 8/11/2020 (General). A fire clearance was issued for the home by Newark Fire Department on 8/13/2020.

Applicant is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Applicant was reminded of the responsibility of a mandated reporter.



Applicant was reminded that California Law requires licensed Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the Applicant that all forms can be downloaded at www.ccld.ca.gov and encouraged the Applicant to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Applicant was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed at 2:45pm. Applicant was reminded that when any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information was provided: US Department of Justice 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.

The Applicant was reminded that any structural changes to the home or additions to the facility must be reported to the Community Care Licensing regional office.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: HASSANI, YALDA
FACILITY NUMBER: 015700151
VISIT DATE: 08/20/2020
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This home is recommended for a provisional license for a large Family Child Care Home on 8/20/2020. This provisional license shall be in effect for a period of three (3) months or until the applicant makes the following changes:

1. Facility Sketch (Floor Plan) must be properly labeled.
2. Certificate for Preventive Health and Safety Training must be provided to LPA upon completion of the training.
3. Photos must be provided of the portion of the backyard behind the above-ground swimming pool demonstrating that it is free of all hazardous/ age-inappropriate materials and dangerous defects/conditions.

Appeal rights were provided. Exit interview was conducted. A copy of this report was emailed to Applicant.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020
LIC809 (FAS) - (06/04)
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