304313559-5-3-2019-06-CC-SHAS-BBTPYM-20190503114410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313559
Report Date: 05/03/2019
Date Signed: 05/03/2019 11:44:26 AM

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:	AKBARI PAZOOKI, PANTEA		FACILITY NUMBER:	304313559
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	05/03/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Pantea Akbari Pazooki		TIME 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	Licensing Program Analyst (LPA) S. Hawkins met with applicant, Pantea Akbari Pazooki and was guided on a tour of the home. Applicant first language is farsi and language link was used to assist in the translation (operator #6630) during todays inspection. This is a follow up prelicense inspection to the home. All areas identified on the facility sketch were inspected. This is a detached two story home with four bedrooms, three bathrooms, living room, family room, office, laundry room, kitchen, and garage. Present in the home during today's inspection was applicant and one additional adult (Behnam Beygzadeh) who was present to assist with translation. Family members residing at facility are two adults and two minor children. A review of staff records on today's date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Failure to complete clearance process or license association for any adult resident or assistant will result in a civil penalty assessment against the license. The home was inspected for safety, comfort, cleanness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Control of property was reviewed. There are age appropriate toys on the premises. The fireplace was observed in the family room and living room that's used for childcare and both was made inaccessible by a screen. An in-ground pool was observed in the backyard with a five foot fence that was not secured and does not meet the department guidelines. Per applicant, there are no weapons or firearms in the facility. The required smoke detector, carbon monoxide, and 2-A 10BC fire extinguisher were observed during inspection. Required postings were observed by LPA. Proof of 8 hour Preventive Health certificate was observed. All day-care activities will take place in the family room, living room, hallway bathroom, office, and enclosed fenced backyard area only which are all downstairs on the first level of the home. LPA observed child safety gate at the top/bottom of the stairs and at the entrance of the kitchen. Child safety latches/ knobs were observed on the laundry room door, kitchen door, , hallway closet door where medication is stored. *continued on page 2*

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: AKBARI PAZOOKI, PANTEA	FACILITY NUMBER: 304313559
	VISIT DATE: 05/03/2019

NARRATIVE

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Page 3/ LIC 809C

LPA explained and reviewed the following sample forms packet that was given during the initial inspection (this was reviewed and translated for clarification):

Children Records: LIC: 700 Identification And Emergency Information, LIC 995E Caregiver Background Check Process, LIC 995A Notification of Parent’s Rights, LIC 627 Consent For Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification, Additional Children in Care. Copies given to applicant.

Facility Records: PUB 394 Notification of Parents Rights, LIC 9040 Facility Roster, LIC 624A Death Report, LIC 6101A Emergency Disaster Plan, LIC 9148 Earthquake Preparedness Checklist, LIC 624B Unusual Incident/Injury Report, and Fire/ Disaster Drill.

Staff Records: LIC 508 Criminal Record Statement, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse, LIC 9163 Request for LIVE-SCAN, LIC 9188 Criminal Record Exemption Transfer Request, LIC 9182 Criminal Background Clearance Transfer Request. Required Immunization's, TB test. (LIC 311D copy given)

--The following was observed and needs correction before a license can be issued:

1. Backyard area behind the home needs an approved pool fence to make pool inaccessible to children in care. The fence currently installed is not stable and does not self latch.
2. Updated facility sketch of the home (upstairs)

Proof of corrections such as pictures need to be submitted to Licensing Office before the due date of 5/10/19. If an extension is needed, please submit a letter in writing before the due date. Report was reviewed and discussed. Exit interview conducted with applicant and language link operator ended the call.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: AKBARI PAZOOKI, PANTEA	FACILITY NUMBER: 304313559
	VISIT DATE: 05/03/2019

NARRATIVE

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Page 2/ LIC 809C
The home has eight finch birds that are kept in a cage that will be kept separate from the children in care. Report is continued on Page 2/ LIC 809

Off limit areas include: All of upstairs which include 4 Bedrooms, 2 bathroom, which was made inaccessible by child safety gate. Attached garage, laundry room, and kitchen located adjacent from the family room which was made inaccessible by child safety latch and gate. Backyard pool area behind the house which will be made inaccessible by fence.

Applicants had the required immunization's on file of Pertussis, Measles, and Influenza during today's inspection. Applicants have completed the mandated reporter training.

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 following were discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to presence in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. No smoking, No infant walkers, No Johnny jumpers, No bouncers, No exersaucer and any other item that falls into that category are not permitted in the facility. Disaster drills, posting requirements, children records, mandated child abuse and injury/death reporting, and criminal records clearances/exemption transfer requests, SIDS and Never Shake a Baby (copy given), Child passenger safety law 2/18(copy given), Centralized Complaint and Information Bureau (copy given), and Advocate Programchildcareadvocatesprogram@dss.ca.gov. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org.A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative. English :https//www.cdph.ca.gov/programs/SIDS/Doucments/SIDSchildcaresafesleep.pdf.

**Report Cont. page 3

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3