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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409018
Report Date: 02/02/2022
Date Signed: 02/02/2022 11:43:22 AM

Document Has Been Signed on 02/02/2022 11:43 AM - 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:MOUSAVI NASAB, SEYEDE DELARAMFACILITY NUMBER:
073409018
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 5DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Delaram MousaviTIME COMPLETED:
12:00 PM
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On 2/2/22 at 9:30 AM Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Annual Inspection at Delaram Mousavi's Family Day Care Home. LPA met with Licensee, Delaram and explained the purpose of today’s inspection. LPA was granted permission to enter the facility. Present in the home were Licensee, her spouse (also helper) and 5 day care children (2 infants, 3 preschool age). Facility is in compliance with required ratios today. Days and hours of operation are Monday - Friday from 7 am - 6 pm. Adults residing in the home are Licensee, Licensee's spouse. All adults have Criminal Background Check Clearances, TB clearance and signed Criminal Record Statements LIC508 on file with Department.

At 9:35 AM LPA toured the INDOOR spaces of the home with Licensee:
In Use Areas: 2 Bedrooms and 1 Bathroom in hallway
Off Limit Areas: Living, Kitchen, Dining, Master Bedroom, Bedroom, Master Bathroom, Entire backyard, attached garage

LPA observed sufficient materials, toys, and play equipment for the day care children in the home. Children were engaged in various activities under the supervision of the Licensee and Helper All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Furniture and equipment, such as cribs, mats, feeding chairs, and tables were age appropriate and in good condition. There were no baby walkers or bouncers observed on the premise during today’s inspection. The home is sanitary, orderly, and safe for the day care children. LPA did not observe any wall heaters in the home. There is a covered fireplace and no stairs inside the home. The Licensee has a working telephone in the home.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
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: MOUSAVI NASAB, SEYEDE DELARAM
FACILITY NUMBER: 073409018
VISIT DATE: 02/02/2022
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LPA observed a fully charged fire extinguisher and working smoke / carbon monoxide detectors. The Licensee states that she does not have any weapons or pets in the home. LPA reviewed a current Children Roster, Emergency Disaster Plan LIC610A. Last fire/disaster drill was completed on 12/21/21. All required postings were observed posted on a wall. The Licensee states that she does not transport children. She supplies snacks and meals to the children. Food storage area was observed to be clean. LPA discussed Healthy Beverages Act with the Licensee. Day care home appeared to be free of flies, other insects, and rodents during today’s inspection.

The outdoor space is off limit presently. There are no bodies of water observed.

FILE REVIEW: At 10:30 AM Children, Licensee, Assistant files reviewed, contained all required documents, Licensee's certifications for CPR/First Aid expire on 7/2022

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during 80% of the operating hours of the day care and ensure that the children are supervised at all times.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

Licensee 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 per day/per person will be assessed if this regulation is violated.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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: MOUSAVI NASAB, SEYEDE DELARAM
FACILITY NUMBER: 073409018
VISIT DATE: 02/02/2022
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

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, no regulatory violations were observed.
Exit interview conducted and report was reviewed with the licensee Delaram Mousavi.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC809 (FAS) - (06/04)
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