198017496-9-25-2019-33-CC-AEIN-BGCRKA-20190925130513

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198017496
Report Date: 09/25/2019
Date Signed: 09/25/2019 01:05:19 PM

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	EBRAHIMI FAMILY CHILD CARE		FACILITY NUMBER:	198017496
ADMINISTRATOR:	EBRAHIMI, GLADYS		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 500-8983
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91206
CAPACITY:	14	CENSUS: 11	DATE:	09/25/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Gladys Ebrahimi, Licensee		TIME COMPLETED:	12:00 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	CASE MANAGEMENT- INCIDENT INSPECTION CONDUCTED IN ARMENIAN Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced case management incident inspection today, due to an incident that occurred on Tuesday, 08/27/19. LPA met with Gladys Ebrahimi, licensee who guided analyst on a tour of the facility. Also present was , Edna Aslanian, licensee's assistant. There were 11 children present in the facility during this inspection. Per licensee, she is partner with Pacific Clinic Head Start program. Alleged Incident took place on 08/27/19. Incident was reported via telephone same working day. Original LIC 624 Unusual Incident/Injury Report form was received by the Department on 09/06/19 by mail. The incident report was dated for Friday 09/06/19. The facility reported the incident within the required 24 hour time frame. LPA observed the area where alleged incident took place. LPA conducted interviews with licensee and child#1. Per licensee, who witnessed the incident, all the children were inside in day care room, while child #1 was playing in day care room, ran towards the no climb bookstand, hit head to the wooden part of bookstand and sustained a cut on left side above the eyebrow. Per child#1, while was playing inside the daycare, hit head to the bookstand and got a cut. Child#1 was taken to emergency room with mother and licensee and received 6 stiches on left side above the eyebrow. Pictures were taken from day care room and a copy of doctor note was received. Ratio and staffing were in accordance of Title 22 Code of Regulations at the time of the incident. Per licensee, at the time of incident there were 9 children with licensee and her assistant. LPA issued the Confidential Names List (LIC 811) to the licensee during this inspection. The Confidential Names List documents the staff and children involved with the incidents documented in this report. REPORT CONTINUES ON NEXT PAGE 1 of 2

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 854-8930
LICENSING EVALUATOR NAME: Anomeh Eivazian	TELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: EBRAHIMI FAMILY CHILD CARE	FACILITY NUMBER: 198017496
	VISIT DATE: 09/25/2019

NARRATIVE

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At this time, there is not a preponderance of evidence that shows that the facility was in violation with Title 22 Regulations when these incidents occurred. Therefore, there are no deficiencies being cited.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Gladys Ebrahimi including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.

REPORT END 2 of 2

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 854-8930
LICENSING EVALUATOR NAME: Anomeh Eivazian	TELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019

LIC809 (FAS) - (06/04)

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