197405723-6-3-2022-30-CC-JLAO-CF2MLW-20220603094300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197405723
Report Date: 05/31/2022
Date Signed: 06/03/2022 09:43:59 AM

Document Has Been Signed on 06/03/2022 09:43 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	HOSSEINKHAH FAMILY CHILD CARE		FACILITY NUMBER:	197405723
ADMINISTRATOR:	HOSSEINKHAH, ZAHRA JAMIL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 992-1212
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	12	CENSUS: 7	DATE:	05/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Zahra Jamil Hosseinkhah		TIME COMPLETED:	02:30 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 5/31/2022 Program Analyst (LPA), Judy Laureano conducted an unannounced Annual Required Inspection and was met by Zhara Hosseinkhah. Licensee’s husband was present during today’s inspection. Days and hours of operation are 6:00 a.m. to 5:30 p.m., Monday through Friday. LPA toured the home inside and outside and a census was taken; 7 children were present during today’s inspections. Current facility sketch reviewed, and Licensee confirmed the following areas are used for the day care: bedroom 1 and bedroom 2, living room, dining room area and the backyard. Applicant confirmed children nap in the living room/dining room area and the younger children nap in bedroom 1. Families access the home by the side metal gate. The following areas are currently OFF LIMITS: the kitchen, bedroom 3 and laundry room area. LPA observed plastic door knob covers making the areas inaccessible. The bathroom that children use is located outside the living room area. LPA inspected and observed the toilet, the sink, sink cabinet and shower area. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible; locked in the laundry room top cabinet. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. Facility does not have any stairs. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 992 1212. Licensee requested to have a

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HOSSEINKHAH FAMILY CHILD CARE	FACILITY NUMBER: 197405723
	VISIT DATE: 05/31/2022

NARRATIVE

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cellphone number added to her file- 818-703-2312.

There are currently 2 infants enrolled in care. LPA discussed Safe Sleep Regulations with licensee and provided hard copies of LIC 9227 Individual Sleep Plan for families to fill out. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Licensee agrees to create a log to documents infants while they sleep. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan will be completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of 7 children’s files and observed files were incomplete and a Technical Advisory was issued. Licensee’s Mandated Reporter Training was not available for review. Licensee agrees to complete online training and submit proof of completion by 6/7/2022. Licensee’s pediatric CPR and First Aid was not available fro review. LPA was able to review licensee’s pediatric CPR/First Aid expires on 10/19/2021 licensee agrees to submit proof of completion and/or registration of class by 6/7/2022 with the help of her daughter.

A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HOSSEINKHAH FAMILY CHILD CARE	FACILITY NUMBER: 197405723
	VISIT DATE: 05/31/2022

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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/inspection-process.

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.

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.

A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Zahra Jamil Hosseinkhah

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/03/2022 09:44 AM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HOSSEINKHAH FAMILY CHILD CARE	FACILITY NUMBER: 197405723
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 infants enrolled did not have a completed LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/07/2022
	Plan of Correction
1 2 3 4	Licensee will have families complete the LIC9227 and email LPA completed documents.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC809 (FAS) - (06/04)

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