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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313673
Report Date: 08/31/2020
Date Signed: 08/31/2020 04:45:35 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: 6DATE:
08/31/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:03 AM
MET WITH:Assistant Maryam BahramiTIME COMPLETED:
12:04 PM
NARRATIVE
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An unannounced case management report was initiated on today’s date by Licensing Program Analyst LPA Barajas. During the Tele Inspection phone scheduling call with Homeira Noori a record review was conducted of the staff personnel and roster. LPA Barajas discovered a staff was not associated to the Home Day care facility.
LPA spoke with Assistant Maryam Bahrami via phone, as Licensee Mina Mastali is out of the country. Assistant advised LPA Barajas only caring for 2 infants and 4 Toddlers who were napping. During today’s inspection the facility was operating within its licensed capacity and within compliance of staffing ratios.
During a phone call to schedule a Tele inspection with facility License Homeira Noori #304313747 based on statement and phone interview conducted with Staff Homeira Noori, who indicated started working at the day care on today’s date 08/31/2020 as an Assistant. Assistant Homeira Noori was physically present at the day care and was left alone with 6 children for a few hours, as assistant Maryam Bahrami had an emergency and stepped out of the facility. Assistant Homeira Noori stated is fingerprinted cleared but is not associated to facility. Staff Homeira Noori, is not associated to the Home Day Care License: Mina Mastali as of 08/31/2020 at 11:00am.
California Code of Regulations, Title 22, Division 12, Chapter, Section 102370(d)(2) is being cited on the attached LIC 809D. A civil penalty of $100 has been assessed for Staff Homeira Noori for being left alone with 6 children and not being associated to facility as of 08/31/2020.
This report cites a Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC 9224 and to be kept in each child's file.
Exit interview was conducted with Assistant Maryam Bahrami via Phone. A copy of the report along with Appeal Rights will be emailed to Licensee with a Read Receipt to acknowledge report was received. If Read Receipt is not functional, Licensee will respond to email stating “I have read and received the report, I acknowledge receipt.” LIC 809 will also be mailed if those options are not available.
End of Report.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2020
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: MASTALI, MINA
FACILITY NUMBER: 304313673
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2020
Section Cited

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102370(d)(2) Criminal Record Clearance(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 102370(j) or.. This requirement was not met as evidenced by:
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Based on phone interview and records review: Staff Homeira Noori is fingerprint cleared, however is not associated to this License as of start work date of 08/31/2020 to:Mina Mastali Facility. Staff Homeira Noori is not associated to the License: Mina Mastali as of 08/31/2020 at 11am time of phone call. This is an immediate risk to the 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) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2020
LIC809 (FAS) - (06/04)
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