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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312845
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:17:20 PM


Document Has Been Signed on 05/16/2023 02:17 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:AZAM, NINAFACILITY NUMBER:
304312845
ADMINISTRATOR:AZAM, NINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 257-8333
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:14CENSUS: 10DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:AZAM, NINATIME COMPLETED:
02:45 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Mrs. Bootorabi. Upon arrival, an Entrance Checklist (LIC 126) was provided to the licensee Nina Azam.

Census upon entry:
Infants:4 Children Over Two: 4
Adults Working Directly with Children: 2 Other Adults: 0

The licensee was operating within the licensed capacity as specified on the license. The Facility Day care hours are 6:30 am-6 pm, Monday through Friday.

During today’s inspection, LPA observed the children playing in the living room with magnetic tiles. There were 2 children napping in the nap room. The primary areas of care for children are the living room, nap room and backyard.

Posted Requirements were reviewed at 9:55 am. Upon arrival, the LPA verified that the following documents were posted in a prominent, publicly accessible area; License, PUB 394 Notification of Parents’ Rights, and LIC 9148 Earthquake Preparedness. The licensee met the posting requirement.



Identify Location & Functioning of the carbon monoxide, smoke detector and fire extinguisher was reviewed at 9:59 am. The carbon monoxide and smoke detector were tested by licensee and fire extinguisher was marked in full. All three items were observed to meet the requirements.

Facility Tour of the inside and outside area began at 9:55 am. The LPA and licensee toured the facility inside and outside. The facility sketch (LIC 999) was verified. Areas stated to be off-limits by the facility

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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: AZAM, NINA
FACILITY NUMBER: 304312845
VISIT DATE: 05/16/2023
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sketch were made off limits by baby safe gates. LPA observed baby safe gates at the entrance of the home by the front door that lead to stairs. The LPA then walked through a hallway that leads to the living room (play area), bathroom, and napping room where children play and sleep. The play room had two baby gates in the entrance of the living room and other opening leading to the kitchen.

There is a fireplace in the living room (play room) screened by structure that looks like a baby gate and is inaccessible to children in care.

The bathroom used for children in care was observed to be clean and sanitary. No detergents, cleaning compounds, or other hazardous items were observed during today's visit.

Medicines, detergents, cleaning compounds and other items that could pose a danger if readily available to children were not observed and areas such as the kitchen that may contain them were not accessible to the children by means of baby gates. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections.



Floors, equipment, and furniture in areas that children are cared for were clean and were observed to be in good repair and free of sharp edges.

Children nap on mats, cribs, play yards and bedding is brought by parents every Monday stated by licensee. All soiled blankets and clothing are put in plastic bags and sent home with child stated by the Licensee.

The outdoor activity space was inspected for compliance at 10:15 am. The backyard was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was maintained and free of dangerous hazards to children. The area that had a slide and play house had gym like tiles on the floor.

During the inspection of the outdoor activity space, items that could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. The licensee and LPA discussed the importance of supervision during outdoor play. The outdoor area had 1 table, 1 play house, 3 toddler cars, and slide. A consultation was provided for some items that could pose a danger to children and corrections were made during the inspection.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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: AZAM, NINA
FACILITY NUMBER: 304312845
VISIT DATE: 05/16/2023
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Records Reviewed began at 10:46 am. The LPA requested to review the LIC 610A Emergency Disaster Plan, Verification of Disaster and Fire Drills, and LIC 9040 Facility Roster. The last drill was conducted on 12/23/2022. The licensee was provided a consultation and reminder of the importance to practice drills and log them. Licensee met the requirements for this section.

Personnel Record review began 10:50 am. The LPA requested completed personnel records 2 of 2 adults working directly with the children for review during today’s inspection. The following documents were reviewed in the files provided by the licensee; CPR First Aid Certification, LIC 9052, Immunization records, TB clearance and LIC 9108, and a Mandated Reporter Training Certificate.

CPR & FIRST AID: Family day-care homes shall ensure that at least one staff member who has a current course completion card in pediatric first aid and pediatric CPR issued by the American Red Cross, the American Heart Association, or by a training program that has been approved by the Emergency Medical Services Authority pursuant to this section and Section 1797.191 shall be on site at all times when children are present at the facility and shall be present with the children when children are offsite from the facility for facility activities.

Licensee CPR Expires 11/19/2024 and Assistant #1 10/30/23

Mandated Reporter Training: Health and Safety Code (HSC) section 1596.8662 requires all licensed child care providers, administrators and employees of licensed child care facilities, and applicants for family child care home licenses to complete child abuse-mandated reporter training and to renew the training every two years. Licensee date of completion 5/3/2023 and Assistant #1 05/03/2023

The facility met the requirements for personnel Records.

Children’s Records Reviewed began at 11:00 am The LPA requested completed children’s records of children enrolled. Children's records were reviewed, and there was a separate, complete, and current record for each child. The LPA reviewed files to verify the following documents Immunization Records, LIC 700 Identification and Emergency Medical Treatment, and LIC 995A Notification of Parents’ Rights. Licensee stated she has liability insurance. The licensee did not meet the requirements at this time due to one child of 10 missing immunization records. A consultation was provided.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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: AZAM, NINA
FACILITY NUMBER: 304312845
VISIT DATE: 05/16/2023
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Individual Sleep Plans and Sleep Logs were reviewed during children record review. LPA observed 4 of 4 of 4 infant from 0-12 months Individual Infant Sleeping Plan [LIC 9227 (3/20)]. A sleep log was reviewed for 1 of 4 infants. Licensee was provided a consultation on the importance of sleep logs for children 0-24 months. Licensee did not meet the requirement during the inspection and stated she would begin logs for children over 12 months today and continue them until 24 months. A consultation was provided and licensee did not have further questions about LIC9227 and Sleep Logs.

A consultation and review of the infant safe sleep regulations was completed during todays visit at 1:41 pm. Licensee did not have further questions.

LPA provided a copy of Infant Safe Sleep Regulations, Safe Sleep Frequently asked questions, and a flier of What Does Safe Sleep Look like.

During the inspection LPA observed the napping room door closed and a consultation was provided to licensee and assistant #1.

This facility provides Incidental Medical Services - IMS: During file review the LPA observed C7 file to state licensee stores an Epi-Pen for child. LPA reviewed the storage of medication and equipment/supplies and reviewed children’s, personnel, and administrative records at 11:27 am. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417.

Record review indicated that licensee and staff #1 were trained on the use of the epi pen on 3/14/2023. LPA reviewed and verified location of medication.

The following was discussed with the licensee:

Incidental Medical Services: If the applicant provides Incidental Medical Services to children in care, such as administering blood glucose monitoring, inhaled medications, Epi-pen or Epi-pen Jr., insulin shots or gastrostomy tube feeding and care, or carrying out other medical orders, a “Plan for Providing Incidental Medical Services” must be completed. This plan will help to ensure that the service can be provided in the safest manner possible. The plan is submitted with the application for a Family Child Care Home License.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: AZAM, NINA
FACILITY NUMBER: 304312845
VISIT DATE: 05/16/2023
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Safe Sleep was observed during today's inspection. Children's play yards and cribs have fitted sheets and no items that can pose a danger to children were observed inside or attached to the napping equipment.

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 temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.

The following are additional resources.
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
The American Academy of Pediatric https://www.aap.org/en/patient-care/safe-sleep/
Safe Sleep Regulations https://cdss.ca.gov/Portals/9/Additional-Resources/Legislation-and-Regulations/Public%20Hearing%20Docs/f031803RegulationsTextOALfinal.pdf

Background Checks :A review of the Facility Personnel Report Summary on this date 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 and 0 minor child living in the facility. The licensee was reminded that any individuals 18 years or older must have a background check clearance.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: AZAM, NINA
FACILITY NUMBER: 304312845
VISIT DATE: 05/16/2023
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LPA provided Guardian Information and website info:
https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Video: https://ccld.childcarevideos.org/family-child-care-providers/background-check-requirements-for-caregivers/

Reminders were discussed at 2 p.m during report review. CCLD website www.ccld.ca.gov was provided to licensees to access regulations, updates, and licensing forms.

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

Other useful resources include https://ccld.childcarevideos.org/family-child-care-providers/

Technical Assistance and Advocacy Bureau: The Community Care Licensing Division, Technical Assistance and Advocacy Bureau will host a webinar via phone or ZOOM to inform providers about the no-cost services offered by the Technical Support Program (TSP).

Webinar Date and Time Tuesday, June 6, 2023, 6:00 p.m.

Register in advance for this webinar: Zoom Registration Link After registering, you will receive a confirmation email containing information about joining the webinar. Tip: Save the link to your Outlook calendar for easy access to the webinar.

https://us02web.zoom.us/webinar/register/WN_fJWLW7U8Q-StwMIlUxMjaA

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 05/16/2023 02:17 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: AZAM, NINA
FACILITY NUMBER: 304312845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on observation, interviewing the licensee and record review, the licensee did not comply with the section cited above by not having sleep logs for children over 12 months which poses a potential health, safety or personal rights risk to persons in care. Licensee was given a consultation on sleep logs for children 0 - 24 months.
POC Due Date: 05/16/2023
Plan of Correction
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The licensee made corrections during the inspection and was given a copy of the regulations for reference. Licensee stated she will begin logs for children 12 months and up as of today
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: 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 observation and interview the licensee did not comply with the section cited above by means of having the napping room door closed during the inspection today which posed a potential health, safety or personal rights risk to persons in care. The licensee was given a consultation and resources given to the licensee for reviewd.
POC Due Date: 05/16/2023
Plan of Correction
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Licensee stated she will maintain the door open during nap time.
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: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
Page: 7 of 10


Document Has Been Signed on 05/16/2023 02:17 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: AZAM, NINA
FACILITY NUMBER: 304312845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviewing licensee and record review of children, the licensee did not comply with the section cited above in having immunization records for 1 of 10 children enrolled in her care which poses a potential health, safety or personal rights risk to persons in care. The license was provided a consultation on immunization. A copy of immunization regulations was provided to licensee.
POC Due Date: 05/16/2023
Plan of Correction
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The licensee stated she would be terminating care until child is fully vaccinated. Moving forward she will ensure that children are vaccinated prior to enrollment.
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: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
Page: 8 of 10


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: AZAM, NINA
FACILITY NUMBER: 304312845
VISIT DATE: 05/16/2023
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The licensee understands they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care for 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.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed, and cited at the time of the visit.

The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: CCR 102425(j)(2), CCR 102425(j)(5), CCR 102418(a)

A consultation for the above citations was provided and licensee will begin to implement corrections as of today 5/16/2023.

An exit interview was conducted with NIna. 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 address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. 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 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/inspection-process

End of Report.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
Page: 10 of 10