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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304311952
Report Date: 01/10/2022
Date Signed: 01/10/2022 12:07:15 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:DASMAH, ELIZAFACILITY NUMBER:
304311952
ADMINISTRATOR:DASMAH, ELIZAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 351-5827
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:14CENSUS: 6DATE:
01/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Eliza DasmahTIME COMPLETED:
12:20 PM
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On 01/10/2022 an Annual required inspection was conducted at the facility by Licensing Program Analyst (LPA), Stella Gutierrez. LPA observed licensee and Batul Zamanian, Assistant caring for 6 children; which included 2 infants and 4 preschool age children. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary conducted on 01/10/2022 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Facility Checklist (LIC 126) was provided to Licensee. During today’s inspection, LPA and Licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of closed locked door and safety first security gate. The on limits are include the living room, Bathroom #1, Bedrooms #1 and #2. Areas on limits are accessible through the front door with other on limits accessible when entering hall area. Licensee stated that the primary care supervision for the children is conducted in the living room area and bedrooms are for nap time purposes. There are working carbon monoxide, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are not any firearms and/or other dangerous weapons in the facility and none were observed during today's inspection. There is a fireplace in the living room that is boarded and barricaded by a book shelf and inaccessible to children in care. The home has age appropriate toys for the ages served.


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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
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: DASMAH, ELIZA
FACILITY NUMBER: 304311952
VISIT DATE: 01/10/2022
NARRATIVE
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LPA verified there is a working telephone service (cellular service). LPA, Gutierrez conducted and outdoor inspection during today's visit. Back yard which is accessed through the hall area toward the back of the home and is gated. LPA observed a sand box with no sand, bikes, toys and other age appropriate tike toys. Licensee was reminded that outdoor has concrete and to provide 100% supervision when children are outside.Licensee stated that there are no bodies of water on the premises. LPA, Gutierrez did not observe any bodies of water during today's inspection. Gate that surrounds the perimeter of the back yard is wood and Licensee was reminded to check for any weathered damage that can cause splinters and if needed to hire or perform maintenance to fix the gate so there will not be a potential hazard to the children in care.

The licensee does have a current roster of children in care and pictures taken today of the facility roster. Children's records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance.) The licensee and assistant’s Pediatric CPR/First Aid certification expired 07/13/2023 and 01/20/2023.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee and assistant were reviewed and within compliance. The licensee does not have proof of immunization against pertussis, and measles, and influenza or written declaration to decline.
Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. Assistant did not have proof of mandated reporter training during today's inspection. Licensee Mandated reporter Training completed on 09/20/2021.
Licensee does not currently provide Incidental Medical Services to any of the children in care. Licensee ws advised that if enrolling a child that need IMS provided that Licensee will report this change to assigned LPA or any other Licensing Program Analyst before providing services to develop a plan for the medical service needed.

** Incidental Medical Services (IMS) policy was discussed. 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. Page 2 of 5

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
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: DASMAH, ELIZA
FACILITY NUMBER: 304311952
VISIT DATE: 01/10/2022
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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) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization's, Pediatric CPR/First Aid, and mandated reporter training.



CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

Safe Sleep Consultation Provided:
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 [facility representative] 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.

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

(IF SPANISH) Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf Page 3 of 4

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 10
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: DASMAH, ELIZA
FACILITY NUMBER: 304311952
VISIT DATE: 01/10/2022
NARRATIVE
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AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
• Always place infants on their backs for sleeping
• 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 as long as they do not have items attached to them
• Infants should not be swaddled or have any items covering them while sleeping
• The temperature of the room should be comfortable enough for an adult to wear a T-shirt and not be too hot or too cold

Licensee stated that she/he understood Safe Sleep and LPA, Gutierrez asked if the Licensee had any questions regarding Safe Sleep for infants. Licensee stated, that she understands and what is required at 10:54 AM . Today LPA did provided proof of infant care plan for both infants present today and a 15 minute log of the infants activities while napping at the facility.


Licensee was reminded that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children.

PIN 21-29-CCP Face Covering Requirements and Guidance for Child Care Providers Regarding Coronavirus Disease 2019 (COVID 19) was provided and licensee was to continue to message the “Three W’s”: Wash your hands. Watch your physical distance. Wear a mask. This face covering guidance is for all individuals 2 years and older, except for the exceptions (child’s development, medical exemptions, etc.) that are outlined by CDPH.

Staff Interview conducted with Licensee at 11:30 AM.

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC809 (FAS) - (06/04)
Page: 5 of 10
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: DASMAH, ELIZA
FACILITY NUMBER: 304311952
VISIT DATE: 01/10/2022
NARRATIVE
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Based on LPAs (observations, record reviews and interviews) the following violation(s) was/were observed is/are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3, Type B citations are being cited during today's inspections. Please see LIC 809D.

Exit interview conducted and report was reviewed with the licensee, Eliza Dasmah.

Appeal Rights and Deficiencies cited today were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) 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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.


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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC809 (FAS) - (06/04)
Page: 4 of 10
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: DASMAH, ELIZA
FACILITY NUMBER: 304311952
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2022
Plan of Correction
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Licensee agrees to have assistant complete the Mandated Reporter Training and submit proof via email to LPA by the date specified of 01/24/2021. Email stella.gutierrez@dss.ca.gov
Please find this training at https://mandatedreporterca.com
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 identifiers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2022
Plan of Correction
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Licensee understand the importance of competing the preventative health and safety training including 1 hour nutrition and lead poisoning prevention. Licenee agrees to complete this requirement by the specified date of 01/31/2022 and submit proof via email to LPA, Gutierrez stella.gutierrez@dss.ca.gov
Please go to the emsa website to find a list of training's.
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: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2022
LIC809 (FAS) - (06/04)
Page: 6 of 10
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: DASMAH, ELIZA
FACILITY NUMBER: 304311952
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2022
Plan of Correction
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LPA, Gutierrez did not observe proof of any immunization's which include, MMR, Dtap, and Flu or Flu waiver for Licensee or assistant. Licensee agrees that this is a requirement and will submit proof to LPA via email for both assistant and herself by 02/07/2022. Extended time give due to the response of the pandemic. Proof to be provided to email stella.gutierrez@dss.ca.gov
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: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2022
LIC809 (FAS) - (06/04)
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