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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402503
Report Date: 07/14/2022
Date Signed: 07/14/2022 12:17:46 PM


Document Has Been Signed on 07/14/2022 12:17 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:ZADEH, MAMAKFACILITY NUMBER:
073402503
ADMINISTRATOR:ZADEH, MAMAKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 827-1805
CITY:PACHECOSTATE: CAZIP CODE:
94553
CAPACITY:14; 14CENSUS: 9DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:MAMAK ZADEHTIME COMPLETED:
12:30 PM
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9:45: Licensing Program Analyst Tasha Alexander met with licensee Mamak Zadeh for an unannounced 1 YEAR/REQUIRED inspection. Present for the inspection were licensee, assistant Zahra Vahidi and 9 children in care consisting of 2 infants and 7 preschoolers. Both infants are over 12 months old. Children's files were reviewed today and were found to be complete.. The home is equipped with a fully charged 2A10BC fire extinguisher, working smoke detector, and working carbon monoxide detector, both were tested today. There is a working telephone in the home, Licensee says her cell phone is her best contact number. LPA will update. Per licensee there are no fire arms on the premises. There are no pools, hot tubs, or other bodies of water at the home. All poisons, cleaning solutions and medications are inaccessible to children and are located under the kitchen sink which is latched and in the upstairs laundry room which is off limits. Both licensee and assistant's CPR and 1st Aid cards expire this month. They are scheduled to update on 7/23/22. The off limits areas are the entire upstairs, which includes 4 bedrooms and the laundry room. Licensee was also informed of the licensing web address (www.ccld.ca.gov) for downloading child care forms and (www.myccl.com) to register to receive child care updates.
A review of staff records on 7/14/22 indicates that all facility staff or other individual who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

CONTINUED ON 809-C

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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: ZADEH, MAMAK
FACILITY NUMBER: 073402503
VISIT DATE: 07/14/2022
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Licensee [or facility representative] was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Effective September 1, 2016, a person may not work or volunteer at a child care center or family child care home unless he or she has been vaccinated against pertussis, measles and influenza or has an exemption. Both licensee and assistant have immunizations in file. Both have declined the flu vaccine



Today the newly implemented mandatory mandated reporter training course has also been discussed. Licensee and Assistant Zahra have up to date certificates, expiring on 4/11/23 and 5/5/23

CONTINUED ON 809-C

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 3 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ZADEH, MAMAK
FACILITY NUMBER: 073402503
VISIT DATE: 07/14/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) 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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.


As a result of this visit, there are no deficiencies cited today. An exit interview was conducted. A notice of site visit was posted.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3