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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407766
Report Date: 04/13/2023
Date Signed: 04/13/2023 04:11:51 PM


Document Has Been Signed on 04/13/2023 04:11 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:SHAMLOU, MARIBELLEFACILITY NUMBER:
073407766
ADMINISTRATOR:SHAMLOU, MARIBELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 339-7900
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:14CENSUS: 3DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maribelle ShamlouTIME COMPLETED:
04:20 PM
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On 04/13/2023 at 1:30 PM, Licensing Program Analyst (LPA) Christina Watts conducted an unannounced annual inspection for Maribelle Shamlou's large family child care home. LPA met with licensee and guided analyst on a tour of the facility. During today's inspection, there were 3 children in care (1 infant and 2 preschool aged children) and 9 children enrolled. Also present during inspection was licensee's mother. Family members residing in the home are licensee, licensee minor children ages 13 and 15 years old and licensee's mother. All adults in the home have Criminal Record Clearance. Facility hours of operations are Monday - Friday from 6:00 AM - 5:30 PM.

This is a two story home which consists of 5 bedrooms, 3 bathrooms, kitchen, formal dining room, dining room, living room, family room, laundry room, attached garage, backyard with fire pit and outside grill.
The children on limits areas: Living Room, Family Room, Kitchen, Dining Room, Formal Dining Room, Downstairs bathroom, attached garage converted into activity/play room, and backyard.
Areas off limits include: Entire second floor which includes 4 bedrooms, 3 bathrooms, upstairs loft, guest bedroom on first floor and laundry room.
The LPA toured all areas used by children during this visit.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and central heating system for safety and comfort. There were safe toys, play equipment and materials observed for children. There are stairs in the home that are made inaccessible for children in care. There is a working telephone in the home. Detergents, poisons, cleaning compounds, medications, and other items which can pose a danger to children are made inaccessible in the home. Per licensee, there are no weapons or firearms in the home. Licensee has an up to code 2A10BC fire extinguisher and working smoke/carbon monoxide detector on the premises. LPA observed a screened electric fireplace in the family room. Licensee last conducted fire drill 03/2023. Licensee stated there are no pets in the home.

*CON'T ON PAGE 2*

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
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 5


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: SHAMLOU, MARIBELLE
FACILITY NUMBER: 073407766
VISIT DATE: 04/13/2023
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*PAGE 2*

LPA inspected the backyard and observed a fully fenced and safe backyard for children. LPA observed age appropriate toys for children to play with. On the left section of backyard, LPA observed a fire pit and outside grill. Licensee stated that fire pit and outside grill has been unplugged and cannot turn on unless a propane tank is attached. Licensee stated that she takes children to the park nearby the facility for outdoor activity. LPA reminded licensee when outside of facility, 100% supervision of children in care is required. LPA did not observed any bodies of water in the facility. Facility provide transportation for children, but licensee understands that children cannot be left alone, unattended in parked vehicles

Children’s records were reviewed to ensure that each child has an Identification and Emergency form. During record review, it was discovered that licensee is currently not logging sleep for infant in care. LPA reminded licensee the importance and requirement of maintaining a sleep log for infants. Licensee stated she will log infant sleep and submit to licensing. The licensee Pediatric First Aid and CPR certificate will expire in 04/2025. Required postings were observed near the entrance.

LPA reminded licensee day care needs to be operated within the limitations and capacity of a Large Family Child Care Home with regards to ratios and that Licensee has to be present in the day care for 80% of the operation hours.


LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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) Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

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SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: SHAMLOU, MARIBELLE
FACILITY NUMBER: 073407766
VISIT DATE: 04/13/2023
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*PAGE 3*

On or before March 30, 2018, any person who works in a child care facility shall complete Mandated Reporter training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers. Licensee has provided Mandated Reporter certificate and the certificate expired 01/2022. LPA reminded licensee of the importance and requirement to maintain an updated copy of Mandated Reporter certificate. Licensing stated she will complete Mandated Reporter training and submit copy of certificate to licensing.

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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

In the areas that were evaluated, there were no violation observed.

Exit interview conducted and report was reviewed with the licensee, Maribelle Shamlou. A notice of site visit was given and must remain posted for 30 consecutive days.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5