197494247-7-13-2021-30-CC-MSIN-C4VSRH-20210713140623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494247
Report Date: 07/13/2021
Date Signed: 07/13/2021 02:07:52 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: 8	DATE:	07/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:31 AM
MET WITH:	Maryam Yousefi Danbali		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	On 7/13/2021 Licensing Program Analyst (LPA) Sislyan, conducted an unannounced Annual Required Inspection and was met by Licensee, Maryam Yousefi Danbali. Also present was Licensee's husband, Morteza Saedi. Days and hours of operation are Monday to Friday from 7:00 AM to 12:00 AM. LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed, and Licensee confirmed that the kitchen, living room, bathroom and one bedroom are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of locked doors. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. The home has working telephone service and LPA confirmed the phone number is (310)619-4558. There are currently 2 infants in care. LPA discussed Safe Sleep Regulations with licensee. There are two play yards for each infant in care, 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. Page 1 of 3

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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: 07/13/2021

NARRATIVE

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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. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is 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 always supervised 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.
Licensee has a current roster of the children. An emergency fire/disaster drill has been completed and documented within the last 6 months. Licensee’s pediatric CPR/First Aid expires on 1/27/2023. 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.
Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.
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SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3

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: 07/13/2021

NARRATIVE

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LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.
This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

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SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC809 (FAS) - (06/04)

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