198020273-6-25-2021-33-CC-AGOK-C4BRQG-20210625131331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020273
Report Date: 06/25/2021
Date Signed: 06/25/2021 01:13:39 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:	DATE:	06/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Farkhondeh Goudarzi		TIME COMPLETED:	01:15 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	Licensing Program Analyst (LPA) Alanna Gontarek conducted an unannounced annual inspection to the above facility. LPA met with Farkhondeh Goudarzi, Licensee who guided analyst on a tour of the facility. Licensee's daughter/ Assistant arrived at facility at 9:15 a.m. and continued tour for LPA. Also present during this inspection, was Licensee's spouse, Licensee’s two Assistants. Per Licensee, there are 13 children that are currently enrolled. The Licensee is within the conditions, limitations, and capacity specified on the license. A current children’s roster was available for review. There were 9 children present upon arrival. Hours of operation are: Monday to Friday from 6:00 a.m. to 6:00 p.m. LPA observed staff and children not wearing face masks. LPA advised to follow current Health Department guidelines and wear masks and provide social distancing due to COVID-19 preventative measures. This is a two-story home which consists of 3 bedrooms located upstairs, 3 bathrooms, kitchen, two outdoor sheds, garage, dining room, living room, play room, front yard, side yards, and backyard (fenced). The daycare areas include: one bathroom near the kitchen downstairs, living room, one room upstairs, play room, kitchen, dining room, and all outdoor areas. LPA observed that there is a fireplace in the living room and is barricaded. Per Licensee, areas off limits to children and parents include: 2 Bedrooms, 2 bathrooms located upstairs, two outdoor sheds, and garage. The licensee provides fresh perishable and non-perishable food in the home in good quality and quantity to meet the needs of the next 3 meals and between meal snacks. The licensee states that one additional adult (Licensee's spouse) is currently living in the home. Per Licensee, she currently has 2 Assistants. All adults present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in the licensed Child Care home. Licensee states that there are no firearms, or firing pins, stored in the home. Page 1 of 5

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna Gontarek	TELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: GOUDARZI FAMILY CHILD CARE	FACILITY NUMBER: 198020273
	VISIT DATE: 06/25/2021

NARRATIVE

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All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via a landline and a cellphone that is used and the cellphone stays at the facility during operation hours. There is ventilation and heating (central). LPA observed children's labeled cubbies used for individual storage space. The following was observed and reviewed during this inspection:

Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children. LPA observed cleaning compounds stored under the sink and had a latch making the compounds inaccessible to children in care. The licensee states that there are no poisons in the home and LPA advised Licensee that storage areas for poisons must be locked with a key or combination lock. The restroom that children use was observed to be safe and sanitary.

Fireplaces and open face heaters are inaccessible to children. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was purchased on 6/14/2021. Smoke and carbon monoxide detectors were tested and are operable.

The home is observed to be clean and orderly. Where children less than five years old are in care, stairs are barricaded. LPA observed two areas of stairs and both were barricaded at bottom and top of the stairs via safety gates, which keeps stairs inaccessible to children. There are toys available for children. LPA observed toys located in living room, dining room, and play room. Per Licensee's Assistant, children use one bedroom upstairs as a nap room for children over 12 months to sleep in. Per Licensee's Assistant, she stays upstairs with all the napping children and has a camera to observe children as well. Declaration was obtained. LPA observed children have individual beds, 5 Pack N' Plays, and cots, including comfortable mattresses, clean linens, blankets, and pillows that are in good repair. Cots and bedding were observed in front storage closet and 5 Pack N' Plays were observed in the nap room upstairs.

All equipment meets the US Consumer Product Safety Commission safety standards. LPA observed that 4 Pack N' Plays (i.e. play yards) have blankets and pillows inside. Per Licensee's Assistant, the 4 Pack N' Plays are used for children over 1 years old. Per Licensee's Assistant, the current infants sleep in a Pack N' Play downstairs in living room. All Pack N' Plays were observed to be free of loose articles and objects.

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SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna Gontarek	TELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: 06/25/2021

NARRATIVE

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There were no objects observed to be hanging above or attached to the side of the Pack N' Plays. LPA observed that play yards do not hinder the entrance or exit to and from the space they are sleeping in. Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Each infant has their individual bedding and is washed weekly as required. Soiled bedding is replaced when wet or soiled and is placed in an area inaccessible to infants. Pacifiers were not observed. LPA advised all pacifiers to not be attached to anything and are labeled. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months should be placed on their back for sleeping. LPA advised the licensee to sleep infants where they can always be directly supervised and advised the licensee against sleeping infants in a separate room. Title 22 Regulation Section 102425(j) Infant Safe Sleep was discussed with the Licensee, including but not limited to documentation that shall be maintained. LPA provided the licensee with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics and Helping you to reduce the risk of SIDS. LPA also consulted and explained Child Abuse Reporting, Never Shake a Baby, and Safe Sleeping practices. Licensing form, LIC 9227, (Individual Sleeping Plan) for infants up to 12 months was explained and issued to the Licensee. Licensee states that infants sleep in the living room and play room.

The provider shall supervise infants while they are sleeping and adhere to the following requirements: (1) The provider shall physically check on sleeping infants every 15 minutes. (2) The provider shall document the following: (A) Labored breathing. (B) Signs of distress, which includes but is not limited to flushed skin color, increase in body temperature, and restlessness. (C) Infants up to 12 months of age who are sleeping in a position other than on their back. 1. If the infant’s Individual Infant Sleeping Plan [LIC 9227 (3/20)] does not have Section C completed, the provider shall return the infant to their back for sleeping. Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: 1. Date. 2. Infant’s name. 3. Time of each 15-minute check. (3) If the provider observes labored breathing or signs of distress as specified in Subsection (j)(2)(B), the provider shall do the following: (A) Immediately notify the infant’s authorized representative. (B) Obtain specific instruction from the infant’s authorized representative regarding action to be taken and make prompt arrangements to obtain medical treatment if necessary. (C)There shall be no delay in obtaining emergency medical treatment for

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SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna Gontarek	TELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: 06/25/2021

NARRATIVE

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the infant if the infant’s condition requires immediate attention. (4) The provider shall be near enough to the sleeping infant to be able to hear them wake up. (5) If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. (A) The provider shall be able to visually observe the infant without moving the door. (6) The provider shall be on the same floor as the sleeping infant. (7) A digital video and audio monitoring device may be used in the home but shall not be used in place of the requirements enumerated in Subsection (j). 102423(a)(2) (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

Currently, children are using the outdoor areas for outdoor play time. Per Licensee's Assistant, there is 100 % supervision while children are playing outside. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that can pose a danger to children on the outdoor yard. The Licensee's Assistant states that supervision is always provided. LPA obtained a declaration.

The licensee and other personnel have completed training on preventive health practices including Pediatric CPR and First Aid. The licensee and Licensee's Assistant's Pediatric CPR and First Aid expires on 6/12/2023. There are first aid supplies available. LPA observed First Aid Kits in dining room.

Per Licensee's Assistant, isolation area is located in the dining room, where child can be supervised.
Children’s records were reviewed, including emergency information and were observed to be complete.
The licensee, and both Assistants have proof of immunization against influenza, pertussis, and measles, and have proof of completion of the Mandated Reporter Training (AB 1207) certificate on file, and is current.

LPA issued a Confidential Names List (LIC 811) to the Licensee's Assistant which documents staff and children’s files reviewed during this inspection.

All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Last drill documented was conducted on 5/21/2021.
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SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna Gontarek	TELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: 06/25/2021

NARRATIVE

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Licensee has 2 hens on the premises, and they are at kept in a chicken coop in back yard during operating hours. Licensee also has a pet hamster that is kept in a cage inside dining area on shelf.

Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted.

LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs. Item that fall into these categories are not permitted in a family child care facility. LPA observed a large trampoline located in the off-limit locked garage. Per Licensee, trampoline is used for Licensee's children outside of operating hours.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

This facility provides Incidental Medical Services – IMS. Per Licensee's Assistant, storage of medication and equipment/supplies are stored in high cabinet in kitchen. Physician's instructions are in child's file. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Section 102417. 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 advised the licensee to access forms, regulations and quarterly updates online at: www.ccld.ca.gov.
Capacity Handout (Small & Large) was provided during this inspection.

At this time, the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today.

Exit interview was conducted with Shiva Goudarzi, Licensee's Assistant. This report (LIC 809), and Appeal Rights, were explained and provided during exit interview. The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit made by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

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SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna Gontarek	TELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

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