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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304205171
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:35:17 PM


Document Has Been Signed on 12/21/2023 03:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 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: 2DATE:
12/21/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:SADEGHIEH, SHAHINTIME COMPLETED:
04:00 PM
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Bootorabi & Jung, the Licensing Program Analyst (LPA), carried out a random inspection at the facility. Upon arrival, the licensee, SADEGHIEH, SHAHIN, was presented with an Entrance Checklist (LIC 126). The day-care hours, as confirmed with the licensee, are from 7:30 am to 4:30 pm, Monday through Friday.
Census:Infants: 1 Preschool: 1 School Age:0
Adults:Working Directly with Children:1 Other Adults:0

During today’s inspection, LPA observed two bedrooms with doors closed. C1 was sleeping in the first bedroom in a play yard with a sleep sack and blanket and C2 was in the second bedroom in a play yard awake (getting ready to go to sleep per licensee).

The licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During today's visit the posting requirements were reviewed. Upon arrival, the Licensing Program Analyst (LPA) confirmed that the following documents were prominently displayed in a publicly accessible area: the License, and PUB 394 Notification of Parents' Rights.

A facility tour of both the indoor and outdoor areas was conducted during today's inspection with the licensee, SADEGHIEH, SHAHIN.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SADEGHIEH, SHAHIN
FACILITY NUMBER: 304205171
VISIT DATE: 12/21/2023
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Inside Tour: The Licensing Program Analyst (LPA) and licensee conducted a collaborative tour of the facility's interior. The areas identified as off-limits included bedroom #3 and #4. These off-limits areas were adequately secured with closed doors. No fire place is gated and closed.

The licensee stated that the children's primary care and play areas are centered in the living room and their napping areas are the two bedrooms.

The licensee has specified the following arrangements:
Napping Arrangements: Children nap in bedroom #1 and #2 room in play yards. A consultation was provided on using play yards for napping areas for children over 2 or to big to use a play yard.


The licensee does not provide blankets and sheets for children in her care. The families bring their blankets and sheets every week or as needed.

Meals & Eating:
The licensee states that they provide breakfast, snacks, and dinner to children in care. Food needing refrigeration is stored in the kitchen's refrigerator.

Toileting: Children use the bathroom next to the bedroom #1. Children who require diaper changes are changed on the bed in a bedroom stated by licensee.

Detergents, cleaning compounds, medicines, and other items that could pose a danger if readily available to children were not observed to be out or accessible. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. The children's bathrooms are clean and sanitary.

Fire Arms: The licensee stated there are firearms and/or other dangerous weapons in the facility and none were observed during today's inspections.

The home has age-appropriate toys for the ages served in the living room.

The location & functioning of the carbon monoxide, smoke detector, and fire extinguisher were reviewed with the license. The fire extinguisher is in the kitchen and marked full. The smoke detector and carbon monoxide were tested and functional.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SADEGHIEH, SHAHIN
FACILITY NUMBER: 304205171
VISIT DATE: 12/21/2023
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Outdoors: LPA and licensee tour the outdoor area. LPA observed one slide and one bicycle. The licensee was reminded that outdoor toys should be in good repair. End of indoor & outdoor tour.

Records Reviewed:The Licensing Program Analyst (LPA) requested to review the LIC 610A Emergency Disaster Plan, Verification of Disaster and Fire Drills, and LIC 9040 Facility Roster. The last drill conducted was September 2023.

The LPA emphasized the importance of keeping documents updated. Additionally, a sample fire drill log was provided, and the licensee was reminded to conduct it every six months. The LPA also conducted a review of the LIC 9040 Facility Roster. The roster was updated and a newer version of the roster was provided during today's visit.

Personnel Records: The LPA requested to review 1 of 1 records of adults working directly with children. The following documents were requested for review CPR First Aid Certification, LIC 9052, Immunization records, TB clearance and LIC 9108, and a Mandated Reporter Training Certificate. The LPA was not able to review a personnel file during inspection due to licensee not having one.

CPR & First Aid was updated and expires 06/10/2025 - No Mandated Reporter was available for review. LPA provided a consultation to licensee.

Children’s Records Review:The LPA requested complete children’s records of 2 of 2 children present during today’s inspection. The LPA reviewed files to verify the following documents Immunization Records, LIC 700 Identificationand Emergency Medical Treatment, and LIC 995A Notification of Parents’ Rights. Children's records were reviewed, and there was a separate, complete, and current record for each child.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SADEGHIEH, SHAHIN
FACILITY NUMBER: 304205171
VISIT DATE: 12/21/2023
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The LPA observed 1 infants from 0-24 months. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and maintained at the facility in the infant’s file. LPA observed and reviewed 0 of 0 LIC 9227 Individual Infant Sleeping Plan in children’s files due to children being older than 12 months The LPA provided a consultation and addressed the licensee's questions. The licensee did not have any further questions at that time.
Sleep Logs
The licensee was reminded that they shall physically check on sleeping infants every 15 minutes and document the following:
1.Labored breathing.
2.Signs of distress, which include but is not limited to flushed skin color, increase in body temperature, and restlessness.
3.Infants up to 12 months of age who are sleeping in a position other than on their back.

The licensee had no record of 15 min checks during today’s inspection.
During today’s inspection, the licensee and LPA discussed the following:
· Stay up to date with LIC 9227 and discuss with parents any new changes.
· Ensure 15 min checks are conducted & logged (The initial of the person checking should be included)
· The importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
· Always place infants on their backs to sleep
· Use only a tight-fitting sheet on the crib or play yard mattress.
· Do not hang any items from the crib or above the crib.
· Keep all items, including blankets, out of the crib or play yard.
· Pacifiers may be used if they do not have items attached to them.
· Infants should not be swaddled or have any items covering them while sleeping.
· The room's temperature should be comfortable enough for an adult to wear a T-shirt and not be too hot or old.
Incidental Medical Services (IMS) policy was discussed and the licensee stated she does not provide IMS currently in her FCCH. For IMS information see Evaluator Manual - 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.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SADEGHIEH, SHAHIN
FACILITY NUMBER: 304205171
VISIT DATE: 12/21/2023
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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)

Commonly Asked Questions American Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Know the Law About The Americans with Disabilities Act and Individuals with Disabilities Education Act https://rrnetwork.org/assets/general-files/Child-Care-Law-Center-ADA_IDEA_Housing-April-2019.pdf

The licensee was informed of the important updates available at www.ccld.ca.gov and may request to be


added to an email list to receive Community Care Licensing Important Notifications from the above website
and selecting Receive Important Updates:
https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/child-care
Family childcare, home providers, have an important role in protecting the health and safety of children. Watch these brief, informative videos to learn more about putting Licensing regulations and requirements into practice. https://ccld.childcarevideos.org/family-child-care-providers/

The licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE SADEGHIEH, SHAHIN, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the licensee [or facility representative] (include name).

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First-level appeals should be sent to the regional manager at the above address.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SADEGHIEH, SHAHIN
FACILITY NUMBER: 304205171
VISIT DATE: 12/21/2023
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A notice of site visit was given and must remain posted for 30 days.
The Notice of Site Visit must be posted on or adjacent to the door.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2023 03:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: SADEGHIEH, SHAHIN
FACILITY NUMBER: 304205171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)(A)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: 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. The provider shall be able to visually observe the infant without moving the door.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observationand record review, the licensee did not comply with the section cited above by means of not having 15 min logs for review or conducting them which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2023
Plan of Correction
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The licensee received a sample log and began doing the logs during the inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 7 of 10


Document Has Been Signed on 12/21/2023 03:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: SADEGHIEH, SHAHIN
FACILITY NUMBER: 304205171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall supervise infants while they are sleeping and adhere to the following requirements: 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above by means of not having the bedroom door open upon LPAs arrival which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2023
Plan of Correction
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The licensee stated that she will maintain the door open moving forward. A copy of safe sleep regulations was provided during the inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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