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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409283
Report Date: 05/26/2022
Date Signed: 05/26/2022 10:50:09 AM


Document Has Been Signed on 05/26/2022 10:50 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:VIJEH, MAHTABFACILITY NUMBER:
073409283
ADMINISTRATOR:VIJEH, MAHTABFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 642-8306
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:14CENSUS: 1DATE:
05/26/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mahtab VijehTIME COMPLETED:
11:00 AM
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On 5/26/22 at 9:00 am Licensing Program Analysts (LPAs), Monica Mathur and Christina Watts conducted an announced CHANGE OF LOCATION Pre-licensing Inspection at Mahtab Vijeh's home and met with Applicant, Mahtab who has applied for a Large Family Child Care Home with a capacity of 14. Days and hours of operation will be Monday – Friday from 8 am - 5 pm. Present in the home were Applicant, her adult daughter who is also the Helper. They were caring for 1 child (age 2).

Applicant is registered to take 8-hour Preventative Health & Safety training on 5/27/22 and submitted proof of registration. Training will include Nutrition and Lead Poisoning training. Applicant has current, 8-hour Pediatric CPR & First Aid (expires 9/22), has documentation for Measles, Pertussis, Influenza for the current flu season. Applicant and her adult daughter are the only residents living in the home; they have Criminal Record and Child Abuse Index Clearance and documentation for Tuberculosis (TB) clearance. Applicant rents the home and has submitted copy of rental agreement. LPA reminded that when care for more than 12 and up to 14 is provided, must notify parents and get landlord consent. Applicant has Liability Insurance for her day care and a working telephone in the home. Fire Clearance was granted and received on 5/12/22.

Single story home comprises of 2 bedrooms, 2 bathrooms, Kitchen, Living/ Play area, Dining/Play area, Office, Detached Garage, Backyard, Left & Right Side Yard
Areas to be used for day care: Living, Dining, Kitchen, 2 Bedrooms, 2 Bathrooms, Backyard, Left Side Yard
Off-Limit Areas: Detached garage, outdoor storage shed, Right Side Yard, Office room.
Isolation Area: Dining/Play area
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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: VIJEH, MAHTAB
FACILITY NUMBER: 073409283
VISIT DATE: 05/26/2022
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LPA toured the indoor space of the home. It is sanitary and orderly, with heating and ventilation for safety and comfort. There are no stairs or fireplace. LPA observed fully charged 2A10BC fire extinguisher, working smoke, carbon monoxide detector. Medicines, cleaning products, sharp objects are stored inaccessible to children in cabinets with latches and locks. Door access to off limit areas are locked. LPA reminded that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. Applicant does not have pets, no arms and ammunition in the home.

Outdoor Space: LPA toured the outdoor areas. Children will be using the Main Yard and Left Side Yard. The yard has fences on all sides. There is a flowing creek behind the backyard, with no access from the home. Fences are high enough and creek is completely inaccessible. Detached Garage and Storage shed in the yard is locked.

LPA discussed and reminded Applicant 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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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

LPA discussed the safe sleep regulations with Applicant, 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 applicant 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.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
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: VIJEH, MAHTAB
FACILITY NUMBER: 073409283
VISIT DATE: 05/26/2022
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Applicant 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.

Website links for provider resources:


Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov.

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 platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The following item to be completed prior to licensure:

1. 8 hour Preventative Health & Safety Training including Nutrition and Lead Poisoning. Applicant will submit proof of completed training. She is registered to take it on 5/27/22.

Facility is recommended for licensure, subject to approval by Management. Exit interview conducted and report was reviewed with the Applicant, Mahtab Vijeh
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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