304312244-4-25-2023-06-CC-DVSA-CR8VRF-20230425163952

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304312244
Report Date: 04/25/2023
Date Signed: 04/25/2023 04:40:01 PM

Document Has Been Signed on 04/25/2023 04:40 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	ASSADZADEH, MINA		FACILITY NUMBER:	304312244
ADMINISTRATOR:	ASSADZADEH, MINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 744-4842
CITY:	VILLA PARK	STATE: CA	ZIP CODE:	92861
CAPACITY:	14	CENSUS:	DATE:	04/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Licensee, Mina Assadzadeh		TIME COMPLETED:	05:00 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	An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Dianna Valdez Santana met with licensee, Mina Assadzadeh census was taken. There was 8 preschool children and 2 infants in care supervised by 3 staff including licensee. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date, 04/25/23 indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults including the licensee living in the facility. Facility Day care hours are 7:30 am-5:00pm, Monday through Friday. During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of locked doors and child safety gates. The childcare area consists of the family room, living room, dining room, kitchen, one bedroom, one restroom and the outside play yard that is accessed through the family room. The children walk through the family room and kitchen to get to the bathroom. Licensee stated the children's primary area is the family room. There are working carbon monoxide, smoke detector alarms 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 no firearms and/or other dangerous weapons in the facility and none were observed during today's inspection. There is a fireplace in the family room covered by a locked glass cover to ensure it is inaccessible to children in care. The home has age-appropriate toys for the ages served. LPA verified there is a working telephone service, which is the licensee’s cellphone. Licensee stated they use the backyard as their outdoor play area. There were no poisons or other items observed which could pose a danger to children. There are no bodies of water on the premises. Page 1 of 4.

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantana	TELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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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Document Has Been Signed on 04/25/2023 04:40 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ASSADZADEH, MINA	FACILITY NUMBER: 304312244
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(b)(3)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interview record, the licensee did not comply with the section cited above in at one play yard had blankets hanging on the side, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2023
	Plan of Correction
1 2 3 4	LPA asked licensee to immediately remove the blankets. LPA provided a consultation about Safe Regulations.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantana	TELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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

FACILITY NAME: ASSADZADEH, MINA	FACILITY NUMBER: 304312244
	VISIT DATE: 04/25/2023

NARRATIVE

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The licensee has a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed. LPA reviewed 5 children’s files. LPA reviewed LIC 9227 Individual Infant Sleeping Plan forms with licensee. LPA observed at least one play yard to have blankets hanging on the side of the play yard. The licensee’s Pediatric CPR/First Aid certification is current and expires 4/2024.

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 two assistants were reviewed and within compliance.

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. During file inspection, it was observed that the licensee had a current Mandated Reporter training certificate, it expires 1/11/2024.

Incidental Medical Services (IMS) policy was discussed. Licensee stated they are not administering medications. 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. 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.

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SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantana	TELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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

FACILITY NAME: ASSADZADEH, MINA	FACILITY NUMBER: 304312244
	VISIT DATE: 04/25/2023

NARRATIVE

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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.

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.

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

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.
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SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantana	TELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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

FACILITY NAME: ASSADZADEH, MINA	FACILITY NUMBER: 304312244
	VISIT DATE: 04/25/2023

NARRATIVE

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Safe sleep consultation provided during today's inspection. Safe sleep 15-minute log for infant present reviewed during today's consultation. LPA Valdez Santana asked Licensee if she had any questions or concerns about Infant Safe Sleep Regulations 102425. A review of this regulation was provided to Licensee.

Based on LPA’s observations, licensee had blankets hanging on the side of the play yards. The following violation was observed and are being cited, see attached LIC 809D.

In the areas that were evaluated, 1 Type B deficiency was observed of the California Code of Regulations, Title 22, Division 12 Sections 102425(b)(3) Infant Safe Sleep at the time of visit.

Exit interview conducted and report was reviewed with the licensee, Mina Assadzadeh. Appeal Rights and 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: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantana	TELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

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