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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405552
Report Date: 07/09/2019
Date Signed: 07/09/2019 02:54:25 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:EBRAHIMI, PARVANEHFACILITY NUMBER:
073405552
ADMINISTRATOR:EBRAHIMI, PARVANEHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 944-2470
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:14CENSUS: 8DATE:
07/09/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:NOORI, PAYAMTIME COMPLETED:
03:15 PM
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3 Licensing Program Analyst, (LPA), R. Hollie, met with the licensee's son, Payam Noori, LPA viewed his fingerprint cleared letter dated, 06/18/19. Also present during this visit, is the licensee's mother S. Roohi and the licensee's elder son, Pedram Noori arrived shortly after the start of the visit. The purpose of this visit is for Random Health and Safety Inspection. The entire home is on limits to the children, the garage is an additional play space. Children sleep in the living room and bedrooms. LPA observed sleeping children during this visit. During the visit LPA provided documentation regarding Safe Sleep Concepts.
Payam Noori, contacted the licensee by phone and she was away at a medical appt.
Per Mr. Noori, there are no bodies of water on the premises nor are there guns on the premises. Poisons, detergents, cleaning compounds and medications are inaccessible to children. There is a working smoke detector and a charged fire extinguisher (2a10bc) as well as a carbon monoxide detector. The home is free of stairs. The home has toys, play equipment and materials for children. The licensee understands that children are to be supervised at all times.
SEE NEXT PAGE FOR CONTINUED REPORT
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2019
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 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: EBRAHIMI, PARVANEH
FACILITY NUMBER: 073405552
VISIT DATE: 07/09/2019
NARRATIVE
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There are no children receiving Incidental Medical Services at this time. The facility is aware that any person's employed or volunteering at a family day care shall be immunized against influenza, pertussis and measles or Must qualify for an exemption.

LPA discussed and advised the facility to check in with parent or guardians if children fail to arrive to the day care as scheduled.

LPA encouraged the facility to review our website at the above address at CCLD.CA.GOV to stay up to date and informed on Laws and Title 22 Regulations as it relates to her day care business, Particularly, the Provider Information Notices, known as PINS



THE FACILITY WAS PROVIDED A COPY OF THEIR APPEAL RIGHTS (LIC 9058 12/15) AND THEIR SIGNATURE ON THIS FORM ACKNOWLEDGES RECEIPT OF THESE RIGHTS. LPA POSTED THE REQUIRED POSTINGS FOR PUBLIC VIEWING. The licensee as informed that if the facility receives a deficiency, the facility must make the corrections by the date on the report (809-d) or the facility will receive a penalty of $100 per day until the deficiency is corrected. The facility was made aware of Safe Sleep Regulation Concepts as it relates to Infants. During the visit, the Licensee was given a copy of the document containing the Sleep Regulation Concepts.

THERE ARE NO DEFICIENCIES CITED TODAY.

SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2019
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: EBRAHIMI, PARVANEH
FACILITY NUMBER: 073405552
VISIT DATE: 07/09/2019
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The facility is aware that children are not to be locked in cars or other areas of the home. The facility was informed that when or if she is temporarily absent from the home, a fingerprint cleared adult, who holds a current CPR/FA must be present in her absence. All of the assistant's have current CPR/FA which expires 03-04-20. The facility shall always maintain the capacity specified on the license. The home appears to have healthful, safe and comfortable accommodations, furnishings and equipment for children. There is a current roster of the children. The home conducts fire and disaster drills. Immunization's are documented. The licensee provides parents with a Notification of Parents Rights.
The Licensee understands that unannounced visits by CCL Employees, provided ID is shown and in the course of business, may enter and inspect areas of her home where she provides personal care and services to children.
The licensee understands that upon notice of the Department to remove an individual from the home, pursuant to H&S Code 1596.871(c)(2) or to exclude an individual from the home, pursuant to H&SCode 1596.8897, the licensee immediately removes the individual and prevents them from returning to the home or having contact with children in care. The licensee must ensure that all adults working, residing or volunteering in a licensed home, must obtain a criminal record review (fingerprint clearance) prior to being in the presence of children.
Children's records were reviewed during this visit.
PLEASE SEE NEXT PAGE FOR CONTINUED REPORT
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3