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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304205171
Report Date: 09/12/2019
Date Signed: 09/12/2019 02:35:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SADEGHIEH, SHAHINFACILITY NUMBER:
304205171
ADMINISTRATOR:SADEGHIEH, SHAHINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 364-3416
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:14CENSUS: 1DATE:
09/12/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:LicenseeTIME COMPLETED:
03:00 PM
NARRATIVE
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An inspection was conducted at the facility by Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek. LPA met with licensee, Shahin Sadeghieh. Census was taken. There was a child napping in one bedroom who was under two years old. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

There is presently one other adult living in the home besides the licensee. During today’s inspection the home and grounds were toured and the licensee was operating within the licensed capacity. The floor plan was verified. Off limits areas are made inaccessible by means of locks. The facility is one story detached. The primary area of day care is the living room, kitchen, hallway bathroom and two bedrooms for the napping of children. The smoke detector, carbon monoxide detector, and fire extinguisher are within regulations. The fireplace is screened.

The backyard designated for outdoor play by children in care is fenced. There are no bodies of water in this facility observed. There are no pets in the house. The licensee pediatric CPR/First Aid certification is current. Items which could pose a danger to children were not accessible to children. Poisonous items were not observed during today's inspection. Appropriate fire extinguisher is in the home. The licensee has a current roster of children in care. Emergency Disaster drill log within the past six months was available. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection.
Children's records: parents' rights and California School Immunization Record were reviewed.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Continued on page 2
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SADEGHIEH, SHAHIN
FACILITY NUMBER: 304205171
VISIT DATE: 09/12/2019
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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 .

There is proof of immunization against pertussis and measles and Flu for the licensee in the house. The Mandated Reporter Training Certificate is not available due to this training is not offered in licensee's native language. Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov

A copy of child care provider's guide to safe sleep pamphlet and a copy of Never Ever Shake a Baby pamphlet with the website www.dontshake.org were given to the facility representative on the last inspection.
An updated pamphlet regarding safe sleep regulations in childcare and a pamphlet for lead poisoning facts were given to the licensee today. A copy of the children's equipment such as walkers, saucer chairss, infant bouncers, recalled rock and play, and Johnny jumpers which are not allowed to keep at the facility was given to the licensee.

Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Appeal rights provided and explained. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional Manager, address is above on the report Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

On today's inspection, the licensee was in compliance with the California Code of Regulations, Title 22; Division 12. No deficiencies were observed and cited.
The exit interview was conducted in Farsi Language.

This report ends here.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2