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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313472
Report Date: 11/22/2023
Date Signed: 11/22/2023 12:00:58 PM


Document Has Been Signed on 11/22/2023 12:00 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:MOUSSAVI, MANDANFACILITY NUMBER:
304313472
ADMINISTRATOR:MOUSSAVI, MANDANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 431-4893
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:14CENSUS: 0DATE:
11/22/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mandan MoussaviTIME COMPLETED:
12:00 PM
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An office meeting with held with licensee Mandan Moussavi with LPA A. Bootorabi and LPM Patricia Magana to discuss the following citations issued on 05/10/2023 during an inspection and to assist the licensee in meeting the requirements of the California Code of Regulations, Title 22, Division 12.

The following was discussed:

CCR 102425(j) – Type A - Infant Safe Sleep: The provider shall physically check on the infant every 15 minutes. The provider shall check and document the following: Labored breathing. Signs of distress include but are not limited to flushed skin color, an increase in body temperature, and restlessness. The licensee did not meet the requirements of the section cited above by means of not having infants' safe sleep logs for review. A consultation and sample copies were provided during today’s meeting.

CCR 102425(j)(5) – Type A - 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 always remain open. LPA observed during the inspection the licensee did not comply with the section by means of having two children sleeping in a separate room from where the provider is stationed, the door to the room was closed.

CCR 102417(g)(4) – Type B - Operation of A Family Child Care Home: (g) The home shall be free from defects or conditions that might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. LPA observed cigarette buds in the backyard and medication in the dining room on a piece of furniture located next to the dining table accessible to children in care which poses a potential health risk to children in care.

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 11/22/2023
NARRATIVE
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Technical Violation
CCR 102419(b): (b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family childcare home at all times children are in care. The licensee was given a consultation on the importance of having the parent board visible to parents.

CCR 102421(b): (b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7). One record was missing for one child out of 9 records reviewed. The licensee will have the parent of C2 complete the record today.

Technical Assistance
CCR 1596.8662(b)(1) : (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. The licensee complete the training along with assistant #1.
HSC 1597.622(c): (c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as outlined in this section, in the person's personnel record that is maintained by the family day care home. A consultation was provided for children (C3 & C6) missing and needing immunization record updates.

HSC1597.622(a)(1): (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. A consultation on getting files ready for inspections was provided on 5/10/2023.

CCR102418(g): (g) 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.


Updates needed on 2 of 9 student files reviewed.

LPM discussed: Webinars for DSS and Resource & Referral Agency - LPM discussed unannounced visits to ensure compliance with Title 22 Regulations. Page 2

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

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 11/22/2023
NARRATIVE
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The licensee stated the following:
CCR 102425(j) – Type A - Infant Safe Sleep: Licensee stated she has kept logs for children since her annual inspection.
CCR 102425(j)(5) – Type A - Infant Safe Sleep: The licensee stated that now she knows that the door should be open.
CCR 102417(g)(4) – Type B - Operation of A Family Child Care Home: The licensee stated that she spoke with her gardener to not smoke on the premises. The licensee understands that their should not be any medication or vitamins accessible to children in care.
TV: CCR 102419(b): The licensee stated she did not know that the parent rights were supposed to be visible to parents coming into the home.
CCR 102421(b): The licensee stated that she has since gotten the emergency form completed.
TA: CCR 1596.8662(b)(1): The licensee has completed with Assistant #1. The licensee was also reminded that any other adults in the home who will be engaged with the children must complete it. The licensee stated she will work on a system to ensure she renews it in 2 years.
HSC 1597.622(c): The licensee stated they received a copy of the immunization record from the parents for the two children missing immunization records.
HSC1597.622(a)(1): A consultation was provided that the licensee and staff should maintain a record or decline notice of influenza on file.
CCR102418(g): The licensee stated that she has updated the files for children. The licensee stated that moving forward she will not accept children without completed records to maintain compliance.

LPM discussed: Webinars for DSS and Resource & Referral Agency - LPM discussed unannounced visits.

Printed Resources Provided:

· LIC 311D – Forms/Records To Keep in Your Family Child Care Home


· Child Care Licensing Program Webinars PIN 22-30-CCP - Tuesday, December 12, 2023, 6:00 p.m.
· Safe Sleep Log Sample
· Active Supervision
· Safe Sleep Regulations
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 11/22/2023
NARRATIVE
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Training to be completed by the licensee:

Family Child Care Provider https://ccld.childcarevideos.org/family-child-care-providers/

Licensee agreed to complete the following training and provide a training certificate to LPA in two weeks Dec 6, 2023

Record Keeping in Family Child Care


Supervising Children in Family Child Care
Health and Safety Training
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4