198020273-7-16-2019-33-CC-BBEL-BE5R5D-20190716124258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020273
Report Date: 07/16/2019
Date Signed: 07/16/2019 12:43:43 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 CARE		FACILITY NUMBER:	198020273
ADMINISTRATOR:	FARKHONDEH GOUDARZI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(657) 321-9884
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90601
CAPACITY:	14	CENSUS: 1	DATE:	07/16/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Applicant Farkhondeh Goudarzi		TIME COMPLETED:	12:45 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	An announced follow-up Pre-licensing inspection was conducted on this date by Licensing Program Analyst (LPA) B. Emiko Bell. The purpose of the inspection was to ensure that all of the nineteen corrections which were suggested during the pre-licensing inspections conducted on 06/18/19 have been completed. Upon arrival, LPA was greeted and let into the residence by applicant, to whom the reason for the inspection was announced. At the time of LPA's arrival, applicant was with one adult and one minor. During today's inspection, the following corrections have been verified to have been completed: 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. An updated LIC 279 was provided to LPA via e-mail and the original was provided to LPA during today's inspection. 2. Complete a Change of Address for her CA driver's license. Applicant provided LPA with a copy of the brown card via text on 07/12/19 and the original was viewed today. 3. Provide LPA with a copy of her lease/rental agreement. Applicant e-mailed LPA a copy of the rental agreement on 06/28/19 and showed LPA the original during today's inspection. 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. On 06/28/19 and on 07/02/19, applicant e-mailed LPA verification of fingerprint clearance, TB clearance, Pediatric First Aid/CPR training and all vaccinations for her spouse and her proposed assistant. 5. Place electrical outlet covers in all unprotected, unused electrical outlets throughout the residence. During today's inspection, LPA observed that all unused electrical outlets now have covers placed in them.

SUPERVISOR'S NAME: Adriana Hernandez	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2019

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: GOUDARZI FAMILY CHILD CARE	FACILITY NUMBER: 198020273
	VISIT DATE: 07/16/2019

NARRATIVE

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17. Provide the Plan for Incidental Medical Services. During today's inspection, applicant provided LPA with a copy of her IMS plan.

Yard:
18. Remove weeds/plant grass. During today's inspection, LPA observed that the weeds have been removed from the backyard. Per applicant, grass will be planted in the front yard when the property owner approves a gardener.
19. Render the wheelbarrow and other tools inaccessible. During today's inspection, LPA observed that the wheelbarrow and other tools have been rendered 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. During today's inspection, LPA was able to inspect the storage shed and the detached garage.

The residence now appears to meet Title 22 Regulations and appears ready for licensure.

An exit interview has been conducted with and a copy of this report has been signed by and provided to Applicant Farkhondeh Goudarzi.

SUPERVISOR'S NAME: Adriana Hernandez	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2019

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: GOUDARZI FAMILY CHILD CARE	FACILITY NUMBER: 198020273
	VISIT DATE: 07/16/2019

NARRATIVE

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6. Finish moving in to the residence. During today's inspection, LPA observed that the applicant appears to be moved in to the residence.

Upstairs:
7. Barricade the top of the stairwell. During today's inspection, LPA observed a baby gate at the top of the stairwell.
8. Ensure that the smoke detector in room 3 works. During today's inspection, the smoke detector was tested and is operable.
9. Replace or remove the broken mirror in room 3. During today's inspection, LPA observed that the broken mirror has been removed.
10. Render room 1 inaccessible (i.e. install a new doorknob handle cover). During today's inspection, LPA observed that a new doorknob handle cover has been installed and that room 1 is able to be rendered inaccessible by being locked by key.
11. Render bathroom 2 (the off-limits bathroom) inaccessible. During today's inspection, LPA observed that bathroom 2 is able to be rendered inaccessible by being locked by key.
12. Render the toiletries in bathroom 1 inaccessible (e.g. buy a shower caddy or remove them). During today's inspection, LPA observed that the toiletries in bathroom 1 have been rendered inaccessible by being placed in a shower caddy.

Downstairs:
13. Replace the baby gate at the bottom of the stairwell. During today's inspection, LPA observed that a new baby gate has been installed at the bottom of the stairwell.
14. Render the knives in the kitchen inaccessible. During today's inspection, LPA observed that the drawer in which the knives are kept now has a childproof latch on it.
15. Show verification of a Parent Board with the required postings. During today's inspection, LPA observed that applicant now has a Parent Board with all of the required postings on it.
16. Render the door to the basement inaccessible. During today's inspection, LPA observed that there is now a latch on the door which leads to the basement.

SUPERVISOR'S NAME: Adriana Hernandez	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2019

LIC809 (FAS) - (06/04)

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