<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313187
Report Date: 04/04/2023
Date Signed: 04/04/2023 03:07:54 PM


Document Has Been Signed on 04/04/2023 03:07 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:GHANBARZADEH, DONYAFACILITY NUMBER:
304313187
ADMINISTRATOR:GHANBARZADEH, DONYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 963-2323
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:14CENSUS: 9DATE:
04/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Donya Ghanbarzadeh, LicenseeTIME COMPLETED:
12:00 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
A 1 year inspection was conducted at the facility by Licensing Program Analyst (LPA) Tran. LPA observed licensee and assistant caring for 9 children including 4 infants. Licensee was operating within the licensed capacity as specified on license. 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. 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. Currently there are 4 adults including the licensee residing in the facility. Facility Day care hours are 8am-5pm, Monday through Friday.

During today’s inspection, LPA and licensee toured the inside and outside areas of the facility. Off limits areas are made inaccessible by means of doors. The childcare area consists of the childcare room which is accessed through the front door and kitchen. The children walk through the kitchen to the bathroom. Licensee stated the children's primary area is the childcare room. There is at least one 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 no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. There is a fireplace in the living room and is inaccessible to children in care. The home has age appropriate toys for the ages served. During today’s inspection LPA verified there is a working phone service. Licensee stated they use the backyard as an outdoor play area. The backyard play area was inspected and is free from hazards. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. There are no bodies of water on the premises.
(Continue next page)
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7


Document Has Been Signed on 04/04/2023 03:07 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: GHANBARZADEH, DONYA
FACILITY NUMBER: 304313187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(f)
Infant Safe Sleep
An infant shall not be swaddled while in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 4 infants in care. LPA Tran obserbved child#1 was being swaddled while sleeping, which poses a potential safety risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
When being addressed, Licensee immediately removed the blanket and child was no londer swaddled while sleeping. LPA reviewed Safe Sleep Regulation with Licensee. Licensee will submit a statement of understading regarding Safe Sleep Regulations on due date.
Type B
Section Cited
CCR
102425(g)
Infant Safe Sleep
An infant’s head shall not be covered while sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 4 infants in care. LPA observed child#1's head being covered on forehead and eyes by a blanket, while sleeping, which poses a potential safety risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
When being addressed, Licensee immediately removed the blanket and child's head was no londer covered while sleeping. LPA reviewed Safe Sleep Regulation with Licensee. Licensee will submit a statement of understanding regarding Safe Sleep Regulations on due date.
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: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7


Document Has Been Signed on 04/04/2023 03:07 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: GHANBARZADEH, DONYA
FACILITY NUMBER: 304313187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

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
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 staff. Assistant did not have a current Mandated Reporter training certification, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
Licensee stated that she will submit an updated Mandated Reporter training certification for her assistant by due date.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
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 included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 4 infants in care. Licensee did not have LIC 9227 for all 4 infants in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
Licensee stated she will submit copies of LIC 9227 for the infants in care by due date.
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: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 04/04/2023 03:07 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: GHANBARZADEH, DONYA
FACILITY NUMBER: 304313187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 4 infants. Licensee did not document the 15-minute checks in sleep log for all 4 infants in care, which poses a potential safety risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
1
2
3
4
Licensee states that she will submit copy of the sleep logs for all 4 infants in care by due date.
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: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


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: GHANBARZADEH, DONYA
FACILITY NUMBER: 304313187
VISIT DATE: 04/04/2023
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
26
27
28
29
30
31
32
(Page 2 of Report)

During today's inspection, LPA observed infant child #1, was swaddled while sleeping in the playpen. In the playpen there were a total of 3 blankets. One of the blanket was covering child's head and eyes. LPA discussed Safe sleep regulation and Licensee removed the blankets from the playpen.

The licensee has a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed. LPA observed 1 infant from 0-12 months. Licensee did not have LIC 9227 Individual Infant Sleeping Plan and Sleep log documented for all 4 infants in care. The licensee’s Pediatric CPR/First Aid certification is current and expires 05/2024. 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 any adult working with children 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. Licensee's assistant did not have a current Mandated Reporter training certification.

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. 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 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 and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training.


LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian (Continue next page)
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: GHANBARZADEH, DONYA
FACILITY NUMBER: 304313187
VISIT DATE: 04/04/2023
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
26
27
28
29
30
31
32
(Page 3 of Report)

CCLD website www.cdss.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. Licensee does/does not have lead training Certificate. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

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. The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.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

Based on LPAs observations, record reviews and interviews, the following violations were observed in accordance with California Code of Regulations, Title 22, Division 12, Section 102425(c), 102425(f) and 102425(g), 102425(j)(2)(D) Infant Safe Sleep, and Health and Safety Code 1596.8662(b)(1) Administration of Child Day Care Licensing, are being cited on the attached LIC 809D.

(Continue next page)

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: GHANBARZADEH, DONYA
FACILITY NUMBER: 304313187
VISIT DATE: 04/04/2023
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
26
27
28
29
30
31
32
(Page 4 of Report)

Appeal Rights were explained. The Licensee was provided a copy of 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. First level appeals should be sent to the regional manager to the address listed above. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Donya Ghanbarzadeh.

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.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7