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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073403929
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:01:19 PM


Document Has Been Signed on 07/27/2023 03:01 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:NOROUZI, EHTERAMFACILITY NUMBER:
073403929
ADMINISTRATOR:NOROUZI, EHTERAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 372-6166
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:14CENSUS: 9DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:EHTERAM NOROUZITIME COMPLETED:
03:15 PM
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Licensing Program Analyst Tasha Alexander met with licensee Ehteram Norouzi for an unannounced 1 YEAR/REQUIRED inspection. Present for today's inspection is licensee, her adult daughter/assistant Mona Iranmahd who is also helping with interpretation and 8 children in care, consisting of 4 infants and 4 preschoolers. LPA toured the facility and backyard for a health and safety inspection and children's files were reviewed. There is a fully charged 3A40BC fire extinguisher, a working smoke alarm and working carbon monoxide detector in the home. All were inspected/tested and found to be in working condition. There is a working telephone in the home, no change in the phone number. . Per licensee there are no fire arms on the premises. There are no swimming pools, hot tubs or other bodies of water located on the premises. All poisons, cleaning solutions and medications are inaccessible to children in care. Licensee and assistant have current CPR & 1st AID cards which expire 7/24/24 respectively. The off-limits areas are: all 4 bedrooms and 2 bathrooms inside of the home. These areas will be inaccessible to children in care by closed and/or locked doors and visual supervision. The primary areas for children in care are: the converted garage (day care room) with 1/2 bathroom, kitchen, living room, family room and the gated off area of the backyard located just outside of the garage side door. Licensee was reminded that baby walkers, excersaucers and baby bouncers are not allowed. 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.

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

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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 4


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: NOROUZI, EHTERAM
FACILITY NUMBER: 073403929
VISIT DATE: 07/27/2023
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A review of staff records on 7/25/23 indicates that all facility staff or other individual who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

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. Today both licensee and assistant have immunization records in file. Licensee and assistant have declined the Flu vaccine last year.

Today the mandatory mandated reporter training course was also discussed. Both Licensee and assistant have up to date certificates- expires 3/23/25.

Infant Safe Sleep practices were discussed. Materials were given and explained. Today all 4 infants are observed to have their own individual play pens to nap in.

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

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: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: NOROUZI, EHTERAM
FACILITY NUMBER: 073403929
VISIT DATE: 07/27/2023
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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.

PLEASE SEE ATTACHED 809-D FOR CITATION


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: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4