304313559-5-29-2019-06-CC-SHAS-BCMMYA-20190529100109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313559
Report Date: 05/29/2019
Date Signed: 05/29/2019 10:01:22 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:	05/29/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Pantea Akbari Pazooki		TIME COMPLETED:	10:20 AM

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 #10398) 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. 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. LPA inspected backyard pool area which consist of a 5 foot mesh fence with door opening swinging away from the pool, it self-closes and have a self-latching device located at the top of the fence. A wall of the dwelling contains a door and window which provide direct access to the pool. LPA observed a separation 5 foot mesh fence between the wall and the pool which makes the pool inaccessible from the kitchen window and child care room door and dining room door. Licensee agrees that the fence will remain in place whenever licensed care is provided, and the fence makes the swimming pool inaccessible to children. Licensee stated that the pool area is identified as an off-limit area and at no time will day care children be allowed in area. 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 was made inaccessible by fence.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019

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: 05/29/2019

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During todays inspection applicant provided LPA with an updated facility sketch to include upstairs area which is identified as off limit.

The home was in compliance with Title 22 Regulations. LPA informed applicant that a final review of the file, will be done before the license is issued. The applicant will be notified if any corrections or additions still need to be completed.

Report was reviewed and discussed. Exit interview was conducted with applicant.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019

LIC809 (FAS) - (06/04)

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