197494247-7-11-2019-30-CC-MSIN-BDYQZU-20190711123719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494247
Report Date: 07/11/2019
Date Signed: 07/11/2019 12:37:41 PM

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:	YOUSEFI DANBALI FAMILY CHILD CARE		FACILITY NUMBER:	197494247
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	07/11/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Maryam Yousefi		TIME COMPLETED:	11:30 AM

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	This is an announced pre-licensing visit conducted by Margarit Sislyan, Licensing Program Analyst, (LPA). LPA met with applicant, Maryam Yousefi, who guided analyst on a tour on 7/11/19 at 09:00 AM. This is 3 bedroom and 2 bathroom single family home. The main care will be provided in the living room and in the bedroom across the living room. Family members residing at facility are: 2 adult and 2 children. The home was inspected for safety, comfort, cleanliness, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Per applicant, there are no weapons or firearms of any kind in the facility currently. The LPA did not observe any weapons. LPA observed there is no pool, spa or other bodies of water on the premises. There are age appropriate toys and equipment on the premises. Applicant has provided proof of Preventative Health and Safety. CPR expires on 02/2021. Applicant has submitted a disaster plan and demonstrated control of property at the above address by presenting by Lease Agreement. The following is needed prior to licensure: 1. Child proof latches shall be installed on the kitchen cabinets to prevent children’s access to the cleaning compounds

SUPERVISOR'S NAME: Sharon Greene	TELEPHONE: (424) 302-3048
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: ((42) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2019

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: YOUSEFI DANBALI FAMILY CHILD CARE	FACILITY NUMBER: 197494247
	VISIT DATE: 07/11/2019

NARRATIVE

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● Emergency Disaster Plan (LIC 610A) - This must be posted in your home next to the telephone and
The Earthquake Preparedness Checklist (LIC 9148), must be attached to the LIC 610A and available
to the public.
● Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home
where all parents can see it
● Facility License, (LIC 203)-Your Family Child Care Home License must be posted in an area of the
home where it can be easily seen.
Employee records must be maintained by the applicant and shall contain the following: LIC9052/Employee Rights, LIC 9108 Mandated Reporter Form, an employment contract or application containing the following information: Employees Full Name, Date of Birth, Driver's License Number, Date of Employment, Documentation of Health and Safety Training, Duties of the employee. Licensee is reminded that records for employees as well as children must be maintained for 3 years after separation for the FCCH.

For additional information and forms visit our website at: www.ccld.ca.gov

SUPERVISOR'S NAME: Sharon Greene	TELEPHONE: (424) 302-3048
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: ((42) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2019

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: YOUSEFI DANBALI FAMILY CHILD CARE	FACILITY NUMBER: 197494247
	VISIT DATE: 07/11/2019

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The following were discussed: No smoking, no infant walkers, Johnny jumpers, exersaucers or any other item that falls into that category.

The LPA also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files and posting requirements. Fingerprint clearance, transfer process and capacity / ratios. Regulation 102416.3 was explained and discussed with applicant. 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) 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

Update on Incidental Medical Services: Facilities that provide Incidental Medical Services (IMS) must identify those services in their facility’s Plan of Operation and submit an updated Plan of Operation to the Department. Incidental Medical Services Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Emptying an Ileostomy Bag. Please see Child Care Quarterly Report on www.ccld.ca.gov

The applicant was informed that all adults living in or having access to the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the is not adhered to, a Civil Penalty of $500 per non-cleared adult will be assessed. Applicant was informed that it is required by law to post the following in the facility:

SUPERVISOR'S NAME: Sharon Greene	TELEPHONE: (424) 302-3048
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: ((42) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2019

LIC809 (FAS) - (06/04)

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