304310436-10-10-2019-06-CC-MMAK-BGTRV9-20191010132109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304310436
Report Date: 10/10/2019
Date Signed: 10/10/2019 01:21:19 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:	JAMKHOO, NOUSHAFARI		FACILITY NUMBER:	304310436
ADMINISTRATOR:	JAMKHOO, NOUSHAFARI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 653-0374
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	14	CENSUS: 4	DATE:	10/10/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Licensee		TIME COMPLETED:	01:45 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	Pg 1 An annual random inspection was conducted at the facility by Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek. LPA met with licensee, Noushafarin Jamkhoo. Present also was Nader Delshadian in one of the bedrooms. According to licensee, Nader has been a guest at her house since a month ago and is planning to stay until end of October 2019. Census was taken. There were a total of 4 children of whom 3 were nude 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 except Nader Delshadian who has been resided at this home day care since a month ago. 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 baby gates and doors which were equipped by locks. The facility is a one story home. The living room, dinning room, one room, and children's bathroom are for day care use. The garage was locked. The back yard was inspected. Back yard is all fenced. There are no high climbing structure or slides in the back yard. The smoke detector, carbon monoxide detector were tested. Fire extinguisher is not within Regulations. There are no bodies of water. The pediatric CPR/First Aid, for the licensee is current. Items which could pose a danger to children were not accessible to children. Poisonous items were not observed during today's inspection. The licensee has a current roster of children in care. Emergency Disaster drill log within the past six months is done. The licensee stated there is no gun in the house. 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 - Regulation Continued on page 2

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2019

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: JAMKHOO, NOUSHAFARI	FACILITY NUMBER: 304310436
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/11/2019 Section Cited	1 2 3 4 5 6 7	Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department. This section was not met as
	8 9 10 11 12 13 14	evidenced by observing adult Nader Delshadian in the house without having fingerprinted clearance. She has been in the facility since one month ago. Licensee failed to meet this requirement. A civil penalty of 500.00 was assessed today. This is an immediate risk to the health and safety of children in care.	8 9 10 11 12 13 14	LPA will check the computer in the office to make sure she has been associated.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2019

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: JAMKHOO, NOUSHAFARI	FACILITY NUMBER: 304310436
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/15/2019 Section Cited	1 2 3 4 5 6 7	Application for License. Licensees and any adult in the home, shall provide evidence of a current tuberculosis clearance, performed and signed by a physician not more than one year prior to or seven days after first day of employment. This section was not met as evidenced by obseving the licensee let an adult reside in her house without TB clearnce
	8 9 10 11 12 13 14	Licensee failed to meet this section of Regulations. This is a potential risk to the health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2019

LIC809 (FAS) - (06/04)

Page: 4 of 4

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: JAMKHOO, NOUSHAFARI	FACILITY NUMBER: 304310436
	VISIT DATE: 10/10/2019

NARRATIVE

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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. Licensee was informed of how/where to access regulations, forms, and Mandated Reporter Training on CCLD website: www.ccld.ca.gov.
Facility was also informed on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov LPA signed the licensee up to receive the quarterly updates from our Department via email.
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.
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.
On today's inspection, the licensee was not in compliance with the California Code of Regulations, Title 22; Division 12 due to . The deficiency was cited on next page on LIC 809D under section 102370(d)(1) for having uncleared adult reside at the facility lacking fingerprinting clearance and section 102369(b)((9) for having an adult reside in the home lacking TB clearance.
Upon receipt, licensee shall post and provide copies of this report to parents/Guardians of children in care and to parents/guardians of children newly enrolled at the facility during the next 12 months. Licensee may use LIC 9224.
The report ends here.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2019

LIC809 (FAS) - (06/04)

Page: 2 of 4