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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313673
Report Date: 10/21/2019
Date Signed: 10/21/2019 01:39:18 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:MASTALI, MINAFACILITY NUMBER:
304313673
ADMINISTRATOR:MASTALI, MINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 750-9494
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:14CENSUS: 0DATE:
10/21/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Mina MastaliTIME COMPLETED:
02:10 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 Analysts (LPAs), Nguyen & Chan conducted an announced Pre-Licensing inspection of the home for the purpose of relocation on today's date. The applicant is moving from her former large family home day care with the license number 304313288. The LPAs toured the home with applicant Mina Mastali. Present at the time of the inspection was the applicant. There is currently one adult and one minor living at the home. The home was clean, orderly, and was at a comfortable temperature. A review of adults' records on today's date indicates that all adults living in the home or individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The facility is a two story home with four bedrooms, four bathrooms, family room, living room, dining room, kitchen, attached garage, front yard and backyard that is fenced. As part of the day-care, the applicant has designated the living room, downstairs bedroom, downstairs bathroom, and backyard. Applicant has placed a child proof gate at the entrance to the staircase that separates the off limit areas which include the kitchen, family room, and all of the second floor. The applicant acknowledged the children may never enter the off-limit areas. The facility has a fireplace in the family room that is screened off. Cleaning solutions/chemicals, utensils, medications and sharp knives located in the kitchen are all inaccessible by high cabinets. Poisons/Hazardous items are stored in the garage. Air conditioning units in the backyard are fenced off to prevent access. There are no bodies of water on the premises.

There are age appropriate toys on the premises for the potential ages served. The applicant stated that there are no firearms on the premises. LPAs advised anytime when firearms are present, they must be locked and stored separately from the ammunition. The smoke detector, fire extinguisher, and carbon monoxide detector were present and within regulations. LPAs observed the 8 hours Preventative Health, CPR & First Aid (exp. 01/2020) are current for the applicant. Current immunization information for pertussis, measles, influenza, and mandated reporter training were verified by LPAs.
Continued on Page 2
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph ChanTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2019
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 3
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: MASTALI, MINA
FACILITY NUMBER: 304313673
VISIT DATE: 10/21/2019
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

The LPAs advised applicant of the Affidavit Regarding Liability Insurance (LIC 282) if did not purchase liability insurance and to maintain the form in the children's files. Applicant understands the home is to be free from smoking at all times and children are never to be left in a vehicle or left unsupervised. Control of property was verified by LPA during today's inspection.

The LPAs advised the applicant to contact licensing for any changes to off limit areas or change in phone number. The applicant has a cell phone that is used for child care. The applicant was reminded that if only a cell phone is used, it must remain on the premises at all times during hours of operation.

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

A Child Care Provider’s Guide to Safe Sleep packet, Lead exposure information and Safety Seat information, Never Ever Shake a Baby and Disaster Preparedness were discussed and provided to the applicant. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf. The below links offer more information on safe sleep to our providers


https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials.

The applicant was also informed to visit the www.ccld.ca.gov website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.

Continued on page 3

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph ChanTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: MASTALI, MINA
FACILITY NUMBER: 304313673
VISIT DATE: 10/21/2019
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

LPAs reviewed Unusual Incident Report form-advised to contact Licensing Officer of the Day within 24 hours and complete the Unusual Incident Report (LIC 624B) within seven days. LPAs reminded the applicant of requirements of disaster drills (documented every 6 months), posting requirements, children records, mandated child abuse and injury/death reporting. LPA advised the applicant of children's rights, including no intimidation, humiliation, and no corporal punishment.

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 need to be completed. Pending review and approval, a large family child care license will be granted.

The following were discussed: The following was discussed with applicant: Individuals who are 18 years of age or older living or working in the home must be fingerprint cleared prior to being present in the facility. If adult is fingerprint cleared and associated to another facility, licensee must complete a Criminal Record Clearance or Exemption Transfer Request form (LIC 9182 or LIC 9188). Appeal Rights were discussed. The applicant was provided with a copy of their appeal rights (LIC 9058 12/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days. First level appeal is to Regional Manager, address is above on the report. An exit interview was conducted, and this report was discussed and provided to the applicant.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph ChanTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3