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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313472
Report Date: 08/13/2019
Date Signed: 08/13/2019 03:57:41 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:MOUSSAVI, MANDANFACILITY NUMBER:
304313472
ADMINISTRATOR:MOUSSAVI, MANDANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 431-4893
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:14CENSUS: 8DATE:
08/13/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:LicenseeTIME COMPLETED:
04:30 PM
NARRATIVE
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An annual inspection was conducted at the facility by Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek. The operation hours are from 7:00 am to 6:00 pm, Monday through Friday. 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.

There is presently one other adult living in the home besides the licensee. During today’s inspection the home and grounds were toured and the licensee was operating within the licensed capacity. Present during today's inspection was the licensee, Mandana Moussavi and her spouse, Abdul Moussavi. There were a total of 8 children present of whom four were under two years old. Four children were in their cribs napping/resting. Four other children were on their mats in the living room napping/resting. The floor plan was verified. Off limits areas are made inaccessible by means of baby gates and locks. The main day care area is the family room, kitchen area, and one bedroom. The kitchen drawers and cabinets were equipped with child proof plastic locks. The licensee pediatric CPR/First Aid certification is current. Items which could pose a danger to children were not accessible to children. Poisonous items were not observed during today's inspection. There is carbon monoxide detector and smoke detector were in the house in working condition. Appropriate fire extinguisher is in the home. The licensee does not have a current roster of children in care. Emergency Disaster drill log within the past six months was available. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection. The backyard is completely fenced. The outdoor play area is free from hazards. There is no high climbing structure/slide equipment observed in the back yard.
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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
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 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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 08/13/2019
NARRATIVE
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Incidental Medical Services (IMS) was discussed with the licensee. 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 .

Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov
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 director 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. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

The deficiencies were cited on LIC 808D attached.

This report ends here.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
LIC809 (FAS) - (06/04)
Page: 2 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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2019
Section Cited
CCR
102417(g)(8)
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Operation of a family childcare home- Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This section was not met as evidenced by licensee's admission that there is no roster at home. The licensee failed to meet this section of regulations.
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Licensee said she will complete the roster and she agreed to submit a copy of the completed current roster to the licensing office by 8/26/19.
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This is a potential hazard to the safe and healthy of children in care.
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Type B
08/26/2019
Section Cited
CCR
102418(g)
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Immunizations- The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This section was not met as evidenced by reviewing children's files. LPA reviewed 8 children's files. Three children
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Licensee said she will obtain the immunization for those three children and she agreed to submit a copy of the completed form to the licensing office by 8/26/19.
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did not have their immunization on file. Licensee failed to meet this section of regulations. This is a potential hazard to the health and safety of children in care.
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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: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2019
Section Cited
CCR
102419(d)(1)
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The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child's file as proof that the parent or authorized
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Licensee said she will have the parents to complete the required forms and she agreed to submit a copy of the completed parents rights form to the licensing office by 8/26/19.
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representative has been notified of his/her rights.......... This section was not met as evidenced by reviewing children's files. LPA reviewed 8 files. Three children did not have this form on file. Licensee failed to meet this section of regulations. This is a potential hazard to the health and safety of children in care.
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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: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4