073409018-7-20-2023-02-CC-MMAR-CTWTVP-20230720150418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073409018
Report Date: 07/20/2023
Date Signed: 07/20/2023 03:04:22 PM

Document Has Been Signed on 07/20/2023 03:04 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:	MOUSAVI NASAB, SEYEDE DELARAM		FACILITY NUMBER:	073409018
ADMINISTRATOR:	MOUSAVI NASAB, SEYEDE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 858-8681
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 7	CENSUS: 5	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Delaram Mousavi		TIME COMPLETED:	03:30 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	On 7/20/23 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Required Inspection at Delaram Mousavi's Family Child Care Home. LPA met with Licensee, Delaram and explained the purpose of today’s inspection. Present in the home were Licensee, her spouse and five (5) day care children (1 infant, 4 preschool age). Facility is in compliance with required ratios today. Days/hours of operation are Monday-Friday from 7am-6pm. Adults present in the home have Criminal Background Check Clearances. IN USE AREAS: Living room, Nap Bedroom (far end of hallway), Hallway Bathroom, fenced area of left backyard portion which is accessed through left side yard gate from the outside. OFF LIMIT AREAS: other 3 bedrooms, Kitchen, Family room, Master bath, Garage, concrete areas of backyard directly outside Family room, Gazebo, Shed. LPA observed sufficient materials, toys, and play equipment. Children were engaged in various activities under the supervision of the Licensee. All detergents, cleaning compounds, medications, and other similar items were inaccessible to children. Furniture and equipment were age appropriate and in good condition. There were no baby walkers, jumpers or bouncers observed during inspection. The home is sanitary, orderly and safe. There is a barricaded fireplace and no stairs in the home. LPA observed a fully charged fire extinguisher that meets State Fire Marshal standards and working smoke/carbon monoxide detectors. There are no pets in the home. LPA reviewed a current Children Roster, Emergency Disaster Plan LIC610A. Last fire/disaster drill was completed 4/6/23. All required postings were observed posted on a wall. Licensee states she does not transport children. She provides snacks/meals and food storage area was observed to be sanitary. OUTDOOR space was inspected. Play equipment was observed in safe condition and free of hazards. The yard was fenced and there were no bodies of water observed.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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: MOUSAVI NASAB, SEYEDE DELARAM	FACILITY NUMBER: 073409018
	VISIT DATE: 07/20/2023

NARRATIVE

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FILE REVIEW: Children, Licensee files were reviewed. Licensee’s Mandated Reporter Training is current and certifications for CPR/First Aid expires 11/2024.

Supervision of children was discussed, and Licensee understands that she must be present in the home during 80% of the operating hours and ensure children are supervised at all times. If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home.

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.

Licensee was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

On this date, 7/20/23, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Subscribe to CCLD important information - Family Child Care Homes: Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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: 07/20/2023

NARRATIVE

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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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.

Exit interview conducted and report was reviewed with the licensee, Delaram Mousavi. During the exit interview, the Licensee, Delaram Mousavi confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

No deficiencies were issued today. Licensee was reminded that all child files must contain Consent for Medical Treatment form LIC627. LPA provided a copy of Records To Be Kept in Family Childcare Home LIC311D. A notice of site visit was given to Licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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