073404786-12-9-2019-02-CC-PPEN-BJPSTV-20191209131010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073404786
Report Date: 12/09/2019
Date Signed: 12/09/2019 01:10:17 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:	GOLZARY, HAMIDEH & DELIJANI, MOHAMMAD		FACILITY NUMBER:	073404786
ADMINISTRATOR:	GOLZARY, HAMIDEH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 223-3793
CITY:	EL SOBRANTE	STATE: CA	ZIP CODE:	94803
CAPACITY:	14	CENSUS: 7	DATE:	12/09/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Hamideh Golzary		TIME COMPLETED:	01:15 PM

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	Licensing Program Analyst (LPA) Paul Petersen conducted an unannounced random annual site inspection for this facility at 1120. At arrival LPA met assistant, Savanah Alvarez Rodriguez. Also present in the child care area were licensee's husband, Mohammad Delijani, and seven children in care, consisting of four infants and three preschool age. LPA began a tour of all areas on limits to children in care and licensee arrived to the child care area from the main part of the residence and assisted with the tour. All adults present are background cleared. The facility is within ratio and capacity. Children are being supervised. The on limits areas are the two child care rooms, the children's bathroom and the nap bedroom. Off limits areas are made inaccessible to children via closed doors or child safety gating and visual supervision. There were no hazardous items/toxins observed to be accessible to children in care. Outlets are safety capped to prevent access by children. There are age appropriate furnishings, play items and equipment, including infant sleeping equipment, which are free of observed broken/sharp pieces. There is heating and ventilation available for safety and comfort. There is a working smoke detector, working carbon monoxide detector and fully charged fire extinguisher. Per licensee, there are no firearms present or stored on the premises. All required postings are present The outdoor patio/play area is fully fenced and on limits to children in care with adult supervision present while children are using the area. There is one swing set present which is securely anchored. There are no pools, hot tubs or other bodies of water accessible to children in care. Continued on Page 2*************************************************************************************

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2019

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: GOLZARY, HAMIDEH & DELIJANI, MOHAMMAD	FACILITY NUMBER: 073404786
	VISIT DATE: 12/09/2019

NARRATIVE

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LPA reviewed the facility, staff and children's records including consents for emergency medical treatment, emergency ID forms and immunization records. Licensee and licensee's husband have current CPR/First Aid certification which expire 12/09/20.

LPA reviewed with licensee the current Facility Personnel Report Summary and verified that all adults age 18 or older who require background clearances have been cleared and associated to this facility.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. 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 (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

The Safe Sleep Awareness Campaign PIN packet was provided and reviewed. Licensee is encouraged to visit www.ccld.ca.gov for licensing regulations and forms. To sign up for quarterly updates contact: childcareadvocatesprogram@dss.ca.gov.

There were no deficiencies cited during this inspection. A notice of site visit was printed and posted and is to remain posted for a period of 30 days. A copy of this report is to be present and available in the facility records for three years from today's date.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2019

LIC809 (FAS) - (06/04)

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