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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406962
Report Date: 07/28/2023
Date Signed: 07/28/2023 01:19:03 PM


Document Has Been Signed on 07/28/2023 01:19 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:HABIBI, FARIDEHFACILITY NUMBER:
073406962
ADMINISTRATOR:HABIBI, FARIDEHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 231-5924
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:14CENSUS: DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:FARIDEH HABIBITIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst Tasha Alexander met with licensee Farideh Habibi for an unannounced 1 YEAR/REQUIRED inspection. Present for today's inspection is licensee, her finger print cleared assistant Sara Brown, and 13 children in care, consisting of 2 infants and 11 preschoolers. Today the facility is out of ratio. LPA toured the facility and patio for a health & 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 is a community swimming pool located on the premises of the complex that is completed fenced and children in care have no access. 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: The entire upstairs,and the sheds located on the patio/backyard. 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 living room/family room, kitchen, downstairs bathroom and backyard/patio. 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: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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: HABIBI, FARIDEH
FACILITY NUMBER: 073406962
VISIT DATE: 07/28/2023
NARRATIVE
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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 licensee has immunization records in file. Assistant Sara's records are unavailable today.

Today the mandatory mandated reporter training course was also discussed. Licensee's certificate is up to date, expires 5/23/25. Assistant's certificate has expired..

Infant Safe Sleep practices were discussed. Materials were given and explained. Today lpa observed 4 play pens for infant napping. Licensee does not currently have any infants 12 months or under.

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: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: HABIBI, FARIDEH
FACILITY NUMBER: 073406962
VISIT DATE: 07/28/2023
NARRATIVE
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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: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/28/2023 01:19 PM - It Cannot Be Edited

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: HABIBI, FARIDEH
FACILITY NUMBER: 073406962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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LICENSEE WILL CONDUCT A FIRE/DISASTER DRILL WITH CHILDREN IN CARE, DOCUMENT AND SUBMIT A COPY OF THE UPDATED LOG TO COMMUNITY CARE LICENSING BY 8/11/23

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2023 01:19 PM - It Cannot Be Edited

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: HABIBI, FARIDEH
FACILITY NUMBER: 073406962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(c)
Administration of Child Day Care Licensing
(c) Current proof of completion for each licensed child day care provider or applicant for that license, administrator, and employee of a licensed child day care facility shall be submitted to the department upon inspection of the child day care or upon request by the department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. TODAY ASSISTANT SARA BROWN'S MANDATED REPORTER CERTIFICATE IS UNAVALABLE
POC Due Date: 08/11/2023
Plan of Correction
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LICENSEE WILL HAVE HER ASSISTANT UPDATE HER MANDATED REPORTER TRAINING AND SUBMIT A COPY OF THE UPDATED CERTIFICATE TO COMMUNITY CARE LICENSING BY 8/11/23
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. TODAY ASSISTANT SARA BROWN'S IMMUNIZATION RECORDS ARE UNAVAILABLE
POC Due Date: 08/11/2023
Plan of Correction
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LICENSEE WILL HAVE THE ASSISTANT OBTAIN A COPY OF HER IMMUNIZATION RECORDS AND SUBMIT A COPY TO COMMUNITY CARE LICENSING BY 8/11/23. RECORDS MUST SHOW PROOF OF MEASLES AND PERTUSSIS VACCINES (MMR & TDAP). ASSISTANT HAS DECLINED THE FLU VACCINE THIS YEAR.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 07/28/2023 01:19 PM - It Cannot Be Edited

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: HABIBI, FARIDEH
FACILITY NUMBER: 073406962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. TODAY ASSISTANT SARA BROWN DOES NOT HAVE THE SIGNED EMPLOYEE RIGHTS RECEIPT IN FILE
POC Due Date: 08/11/2023
Plan of Correction
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LICENSEE WILL HAVE ASSISTANT SIGN THE EMPLOYEE RIGHTS FORM TO BE PUT INTO HER FILE. LICENSEE WILL SUBMIT A COPY OF THE RECEIPT TO COMMUNITY CARE LICENSING BY 8/11/23
Section Cited
General Provisions and Definitions
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2023 01:19 PM - It Cannot Be Edited

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: HABIBI, FARIDEH
FACILITY NUMBER: 073406962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. TODAY THE FACILITY ROSTER IS NOT UP TO DATE
POC Due Date: 08/11/2023
Plan of Correction
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LICENSEE WILL UPDATE HER FACILITY ROSTER AND SUBMIT A COPY OF THE UPDATED ROSTER TO COMMUNITY CARE LICENSING BY 8/11/23
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. TODAY THERE ARE NO SLEEP LOGS TO REVIEW
POC Due Date: 08/11/2023
Plan of Correction
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LICENSEE WILL IMMEDIATELY BEGIN KEEPING A SLEEP LOG FOR ALL INFANTS IN CARE. LICENSEE WILL PHYSICALLY CHEDK NAPPING INFANTS EVERY 15 MINUTES AND DOCUMENT. LICENSEE WILL SUBMIT A COPY OF THE NEW LOG TO COMMUNITY CARE LICENSING BY 8/11/23
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 07/28/2023 01:19 PM - It Cannot Be Edited

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: HABIBI, FARIDEH
FACILITY NUMBER: 073406962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.5(d)(2)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. TODAY UPON ARRIVAL THE FACILITY IS OUT OF RATIO BY 1 PRESCHOOL CHILD
POC Due Date: 07/31/2023
Plan of Correction
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LICENSEE WILL REDUCE THE AMOUNT OF PRESCHOOL AGE CHILDREN BY 1 BY THE NEXT BUSINESS DAY (MONDAY). WHEN AT FULL CAPACITY, THE 13TH AND 14TH CHILD/REN MUST BE AT LEAST 5 YEARS OLD AND CURRENTLY ATTENDING KINDERGARTEN AND AT LEAST 6 YEARS OLD OR OLDER. TODAY THERE ARE 11 PRESCHOOLERS AND 2 INFANTS.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 8 of 9