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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198007903
Report Date: 09/14/2021
Date Signed: 06/28/2022 01:01:15 PM


Document Has Been Signed on 06/28/2022 01:01 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/15/2021 08:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

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AMENDED REPORT: to correct typo and add "Exit interview conducted with Licensee Hosseinzaden"
Licensing Program Analyst (LPA) Warren Birks conducted an unannounced Required 1 Year inspection. LPA met with Licensee Khadijeh Hosseinzadeh who guided LPA on a tour of the facility. LPA observed one preschool child. There are currently is one child enrolled. The children's roster is current. Disaster drill log was also available and current during today’s inspection August 1, 2021.

The facility is a two story, six bedroom, five bathroom home. The following areas are used for day-care: Family Room, kitchen, half bathroom, one bedroom (downstairs). Off limit areas include: All upstairs, five bedrooms, backyard, & detached garage. LPA observed a small dog in the backyard. Licensee indicated that the back yard is off limits and the dog does not commingle with the day-care children. LPA advised Licensee to provide extra care and supervision as animals may be unpredictable. Licensee stated that most of the care happens in the family room. LPA also observed a safety gate barricading the bottom stairs.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. There is a working telephone maintained in the home. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. LPA informed Licensee that poisons must be locked with a key or combination lock.



Per Licensee there are no firearms, weapons or bodies of water on the premises. Safe toys, play equipment and materials were observed. The Emergency Disaster Plan, Parents Rights and License was posted on a poster board. Children’s records were reviewed to ensure that each child has the required documentation including Identification and Emergency, Immunization and Parents Rights. The valve on the required 2A 10BC fire extinguisher is fully charged and is due for service February 2022. Smoke and carbon monoxide detectors are in operable condition. The Licensee has current Pediatric First Aid/CPR. Mandated Reporter Training (expires May 2022)
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: HOSSEINZADEN FAMILY DAY CARE
FACILITY NUMBER: 198007903
VISIT DATE: 09/14/2021
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Proof of immunization against influenza, pertussis, and measles for the Licensee was readily available during today’s inspection.

The following was discussed: Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

LPA reminded Licensee that all rooms that are off-limits need to be remain inaccessible during operating hours. No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility. Effective January 1, 2010, licensees of family child care homes are required to ensure that at least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when children are present.

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

LPA informed Licensee of appropriate sleeping arrangements for infants. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. An extra copy of the LIC 9227 will be emailed to Licensee. LPA explained form is available on CCLD website.

The Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: HOSSEINZADEN FAMILY DAY CARE
FACILITY NUMBER: 198007903
VISIT DATE: 09/14/2021
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AMENDED REPORT: To correct typo and add "Exit interview conducted with Licensee Hosseinzaden"

LPA discussed LIC 311D - Forms/Records to Keep in Your Family Child Care Home. Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed. Role and responsibilities of being a Mandated Reporter were reviewed. The Licensee was advised how to access forms and Regulations online at www.ccld.ca.gov. Licensee was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care.

LPA consulted and explained Child Abuse Reporting, Updated Parent’s Rights Poster with Complaint Hotline information, Never Shake a Baby, Sudden Infant Death Syndrome (SIDS), and Safe Sleeping practices which always Baby is sleeping on his/her back. Capacity Handout (Small & Large) was provided during this inspection. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (use LIC624B for written report). Mandated reporter training must be completed every 2 years. www.mandatedreporterca.com

LPA also discussed Covid Self Assessment and Covid safety according to the Los Angeles County Health Department.There were no citations issued at this time.

Exit interview was conducted with Licensee Small. The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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