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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020273
Report Date: 06/18/2019
Date Signed: 06/18/2019 03:37:26 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:GOUDARZI FAMILY CHILD CAREFACILITY NUMBER:
198020273
ADMINISTRATOR:FARKHONDEH GOUDARZIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(657) 321-9884
CITY:WHITTIERSTATE: CAZIP CODE:
90601
CAPACITY:14CENSUS: 0DATE:
06/18/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant Farkhondeh GoudarziTIME COMPLETED:
03:30 PM
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An announced Pre-licensing inspection was conducted on this date by Licensing Program Analyst (LPA) B. Emiko Bell. Upon arrival, LPA was greeted and let into the residence by applicant, to whom the reason for the inspection was announced.

Applicant's proposed days and hours of operation are Monday-Friday, 6:00 A.M.to 06:00 P.M. She proposes to care for children ages newborn to six years old. This is a single family, two-story historical residence with an attic, a basement, three bedrooms and two and a half bathrooms. All areas identified on the facility sketches were inspected in the following order: (indoors): the second floor, the first floor, and (outdoors): the yard.

The following areas have been designated off-limits: (first floor): the basement, (second floor): Room one bathroom #1; and (outdoors): the garage and both storage sheds. Per applicant, all off-limits areas will be rendered inaccessible by being locked by key. The second stairwell is off-limits and is rendered inaccessible on the bottom by a mounted baby gate and at the top, by a sealed door.

Physical Plant: The residence was inspected for safety, comfort, cleanliness, telephone service (applicant has a cell phone), heating and ventilation (there is a wall unit air-conditioner in the living room, ceiling fans in each bedroom, the kitchen and the activity area), inaccessibility to poisons, detergents, cleaning compounds (kept under the kitchen sink, which has a childproof latch,) medicine (which is going to be stored in bathroom #1) and other hazardous items that can pose a danger to children.

Toys and napping equipment: There are age-appropriate toys on the premises. Applicant has one playpen. Per applicant, she will ask the parents to provide mats and cots for their children to nap on.

Parent Board: As parents will enter from the side gate off of Hadley, applicant proposes to place her Parent
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
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 6
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: GOUDARZI FAMILY CHILD CARE
FACILITY NUMBER: 198020273
VISIT DATE: 06/18/2019
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$100 per day Civil Penalty, for a maximum of 5 days for the first violation and a maximum of thirty (30) days for subsequent violations. If an individual has a clearance with the Department, a criminal record clearance may be transferred. LIC 9182 Criminal Background Clearance Transfer Request may be used.

No smoking; no infant walkers, Johnny jumpers, exersaucers and any other items that fall into that category; earthquake & fire disaster drills and safety; posting requirements; children's records requirements; mandated child abuse and injury/death reporting; criminal records, child abuse clearance, and criminal records transfer requirements.

The following sample forms packets were provided to and reviewed with applicant:

Children's Records: LIC311D Forms/Records To Keep In Your Family Child Care Home; LIC700 Identification and Emergency Information; LIC702 Child's Pre-Admission Health History; LIC995E Caregiver Background Check Process; LIC995A Notification of Parents Rights; LIC995E Caregiver Background Check Process; LIC9212 Family Child Care Consumer Awareness Information; PM286 California School
Immunization Record; LIC627 Consent for Emergency Medical Treatment; LIC613A Personal Rights; LIC282 Affidavit Regarding Liability Insurance; and LIC9150 Parent Notification, Additional Children in Care;

Facility Records: LIC 311D Information To Be Posted In Your Family Child Care Home; LIC9149 Property Owner/Landlord Consent; PUB394 Notification of Parents Rights; PUB269 California Child Passenger Safety Law; LIC9040 Facility Roster; LIC610A Emergency Disaster Plan; LIC9148 Earthquake Preparedness Checklist; a sample fire, earthquake, and smoke detector drill record; LIC624B Unusual Incident/Injury Report; PUB271 Never Shake A Baby; "Reduce the Risk of Sudden Infant Death Syndrome" pamphlet; "Safe Sleep Policy for Infants in Child Care Programs" and "A Safer Generation of Cribs" and "Your Guide to New Crib Standards" by US CPSC .

Staff Records: LIC 311D Facility Forms/Records; LIC508 Criminal Record Statement, LIC501 Personnel Record, LIC503 Health Screening/TB, LIC9052 Employee Rights, LIC9108 Statement Acknowledging Requirement to Report Child Abuse, LIC9163 Request for LIVESCAN, LIC9188 Criminal Record Exemption
Transfer Request, LIC9182 Criminal Background Clearance Transfer Request, and LIC9052 Employee Rights.
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: GOUDARZI FAMILY CHILD CARE
FACILITY NUMBER: 198020273
VISIT DATE: 06/18/2019
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Applicant will inform LPA when the above has been completed. Applicant will need to complete the above within thirty days (by July 18, 2019) or her application may be denied.

An exit interview has been conducted with and a copy of this report has been signed by and provided to Applicant Farkhondeh Goudarzi. Appeal Rights have been provided and explained to same.
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: GOUDARZI FAMILY CHILD CARE
FACILITY NUMBER: 198020273
VISIT DATE: 06/18/2019
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Prior to licensure, applicant will need to complete the following:
1. Complete a new LIC 279 Application for a Family Child Care Home to include her spouse and any other adults who are going to live in the residence's names.
2. Complete a Change of Address for her CA driver's license.
3. Provide LPA with a copy of her lease/rental agreement.
4. Ensure that her spouse and any and all assistants obtain fingerprint clearance and provide verification of TB clearance, MMR/TDAP/influenza vaccinations and Pediatric First Aid/CPR training as necessary.
5. Place electrical outlet covers in all unprotected, unused electrical outlets throughout the residence.
6. Finish moving in to the residence.
Upstairs:
7. Barricade the top of the stairwell.
8. Ensure that the smoke detector in room 3 works.
9. Replace or remove the broken mirror in room 3.
10. Render room 1 inaccessible (i.e. install a new doorknob handle cover).
11. Render bathroom 2 (the off-limits bathroom) inaccessible.
12. Render the toiletries in bathroom 1 inaccessible (e.g. buy a shower caddy or remove them).
Downstairs:
13. Replace the baby gate at the bottom of the stairwell.
14. Render the knives in the kitchen inaccessible.
15. Show verification of a Parent Board with the required postings.
16. Render the door to the basement inaccessible.
17. Provide the Plan for Incidental Medical Services
Yard:
18. Remove weeds/plant grass.
19. Render the wheelbarrow and other tools inaccessible.

As one storage shed and the detached garage were locked by key and could not be inspected, LPA will need to inspect both prior to licensure.
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: GOUDARZI FAMILY CHILD CARE
FACILITY NUMBER: 198020273
VISIT DATE: 06/18/2019
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Board either outside on the patio area or on the wall directly facing the entryway from the side gate (between
the door to the Study Room and the door to bathroom #2.5). All required postings were provided to applicant today (the license, the Notification of Parents Rights, the Emergency Disaster Plan and the Child Passenger Safety Law).

Pets: Applicant currently does not have any pets.

Fire safety: Applicant has a fire extinguisher, size 3-A:40-B:C, which is mounted on a wall in the kitchen by the door which leads to the backyard. Verification was posted on the extinguisher that it was purchased on 01/23/19. There are three carbon monoxide detectors: on the ceiling at the top of the stairs on the second floor; all were tested during today's inspection and are operable. There are six smoke detectors on the premises; all were tested during today's inspection and only the one in Room #3 was not operable. On the second floor, there is one in room #1 and one in room #3. On the first floor, there is one in the Study Room, one in the living room, one in the Activity Area and one in the kitchen. There is a screen in front of the fireplace in the living room.

Transportation: At this time, Applicant stated that she will not offer transportation.

Firearms/weapons: Applicant states that there are currently no firearms or weapons on the premises.

Incidental Medical Services: This facility plans to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Section 102417. 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.

The following was discussed: Individuals who are 18 years of age or older living in the home must be fingerprint cleared prior to licensure. Individuals within one month of their 18th birthday must be fingerprinted immediately. The existing, immediate $100 per individual Civil Penalty has been increased to an immediate
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: GOUDARZI FAMILY CHILD CARE
FACILITY NUMBER: 198020273
VISIT DATE: 06/18/2019
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Community Care Licensing web site address: http://www.ccld.ca.gov. Many of the forms used by CCLD are available via the Internet at the CDSS web site. Most providers need our LIC forms, which are available in English, Spanish, and Chinese at: http://www.dss.cahwnet.gov. PUB brochures and notices can also be accessed at the CDSS web site and are available in both English and Spanish.

Backyard: The backyard is a wrap-around backyard in that it wraps all the way around the entire house. The front yard faces east. The east and south side are fenced by a cement wall with wrought iron on top; the west side is fenced by a cement wall and a motorized gate; and the north side is fenced by a chain-link fence with wood slats placed in between the chain-link. There is vehicle access from both a wrought iron gate on the south side which a vehicle can drive through the back yard to the motorized gate on the west side or vice versa.

Paperwork: Applicant completed online orientation on 01/18/19. Applicant completed Mandated Reporter Training on 04/26/19. Applicant completed Preventative Health and Safety training on 02/03/19. Applicant's Pediatric First Aid/CPR expire 01/21 (they were issued by an EMSA-certified provider). Applicant provided verification of MMR, TDAP, and influenza.

Applicant was previously licensed from 04/01/95-06/29/05 through OCRO. As she has the qualifying experience, she will thus be licensed as a large FCCH, capacity 14. Fire clearance was granted on 06/12/19 for a large FCCH.

Applicant has been advised of the following:
*Fire and earthquake drills to be conducted every six months (for small FCCH) and monthly (for large FCCH.)
*Outdoor supervision is required at all times. If the outdoor area is not adequately fenced, the provider must be with the children at all times when outdoors. Licensee's initials ( ).
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
LIC809 (FAS) - (06/04)
Page: 6 of 6