304313749-4-29-2020-06-CC-ECOL-BP5VM5-20200429163259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313749
Report Date: 04/29/2020
Date Signed: 04/29/2020 04:34:42 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:	RASTEGARI, MAHIN		FACILITY NUMBER:	304313749
ADMINISTRATOR:	RASTEGARI, MAHIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 349-7736
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	14	CENSUS: 0	DATE:	04/29/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Applicant - Rastegari, Mahin		TIME COMPLETED:	02:25 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	Tele-Inspection Licensing Program Analyst (LPA) Corral conducted an announced Pre-licensing Tele-Inspection of the facility on today's date with the Applicant Mahin Rastegari using FaceTime. A review of the Facility Personnel Report Summary conducted on 04/29/2020 indicates all facility residents, staff, or other individuals who require criminal background check clearances or exemptions. The only resident in the home is the Applicant, Mahin Rastegari. Applicant was the only adult present in the home during the Tele-Inspection. The facility is a two-story home with 2 bedrooms, 2 bathrooms, kitchen, dining room, living room, an added room that has been turned into a classroom and the back yard. The classroom addition will be used as the main day care area. The rooms accessible to children in care are the classroom that behind the living room, the dining room, the kitchen, and the bathroom which is accessible through the classroom by two separate entrances. The backyard is also accessible to children by 2 different doors that are located in the classroom. The backyard contained toys, playhouses, tricycles, balls and scooters. Applicant was advised outside play requires supervision. Applicant also has many fruit trees and 5 chickens in the back yard which are enclosed. The off-limit areas of the home is the entire second floor where the 2 bedrooms are and the other bathroom. The second floor is made inaccessible by two gates placed on each side of the hallway that lead to the staircase. Applicant is aware that off limits areas must be completely inaccessible during hours of operation. During the kitchen Tele-Inspection, the knives were located in a kitchen cabinet inside a container that is above 5 feet high. The facility does have a fireplace which was covered by a safety screen and inaccessible to children in care. A wall heater and a wood stove were not observed to be present in care. Continued to Page 2.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Eileen Corral	TELEPHONE: (714) 743-8354
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2020

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: RASTEGARI, MAHIN	FACILITY NUMBER: 304313749
	VISIT DATE: 04/29/2020

NARRATIVE

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Medication was stored in the kitchen and made inaccessible by being placed above 5 feet high. Cleaning supplies and detergents were also stored in a kitchen cabinet above the refrigerator 5 feet high. Poisons and hazardous items were not stored on site, and none were observed during today’s Tele-Inspection. Applicant was advised poisonous items must be key or combination locked. Control of Property was verified by LPA. The applicant has a cell phone that is used for childcare. The applicant was informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation. Applicant was advised and acknowledges the home is always to be a smoke free environment.

Toys and games were observed to be age appropriate and in good condition for the potential ages served. Applicant was advised baby walkers, bouncers, jumpers, and similar items may not be used for children in care. Applicant stated there are no firearms in the home, applicant was informed that if firearms are present, they must be locked and stored separately from ammunition. During today's Tele-Inspection the smoke detector and carbon monoxide were operable and located in the classroom, the fire extinguisher was also charged and located in the children classroom on the door leading to the backyard. Applicant’s Pediatric CPR & Pediatric First Aid expires on 07/2021. Applicant completed the 8-hour EMSA Pediatric Preventative Health on 04/11/2020.

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 was discussed with applicant: Individuals who are 18 years of age and older living or working in the home must be fingerprint cleared prior to being present in the facility. LPA provided applicant with website for Live-Scan locations www.oag.ca.gov/fingerprints/locations and informed applicant all adults must complete Live Scan Application (LIC 9163).

Continue to Page 3.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Eileen Corral	TELEPHONE: (714) 743-8354
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2020

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

FACILITY NAME: RASTEGARI, MAHIN	FACILITY NUMBER: 304313749
	VISIT DATE: 04/29/2020

NARRATIVE

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If adult is fingerprinted cleared and associated to another facility, licensee must submit a Criminal Record Transfer Request (LIC 9182) or Exemption Transfer Request (LIC 9188). Applicant was also informed to contact Licensing Office (714)703-2800 ask for Personnel ID # and fax (LIC 9182 or LIC 9188) with a copy of a valid State or Federal Government ID and Criminal Record Statement (LIC 508) to fax # (714)703-2831 prior to hiring adult. Failure to complete the clearance process or license association for any adult resident or assistant will result in a civil penalty assessment against the license.

LPA reviewed Unusual Incident Report (UIR) form (LIC 624B) applicant was advised to contact Licensing Office within 24 hours and complete the UIR within seven days by faxing LIC 624B to fax provided above. LPA advised applicant to report any unusual incident or child absence that threatens the physical, emotional health or safety of any child in care.

LPA reviewed with applicant requirements of Disaster Preparedness drills which must be documented every 6 months. LPA advised of Affidavit Regarding Liability Insurance (LIC 282) if liability insurance was not purchased and to maintain the form in the children's files. Car Safety Seat pamphlet was provided to applicant. Posting requirements were also discussed which include but not limited to Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Parents Rights (PUB 394), Notice of Site Visit (LIC 9213), and License (LIC 203). LPA reviewed with applicant the need to maintain records including but not limited to Children records and Staff/Adults Records (LIC 311D) was thoroughly reviewed with Applicant. Applicant was informed of Mandated Reporter Training for self and all assistants. Department website was provided for applicant to download forms, Title 22 regulations, and training on-line at http://www.ccld.ca.gov. The applicant was also informed to visit the 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.

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.
A copy of “A Child Care Providers Guide to Safe Sleep” was emailed to applicant.
AAP: www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
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SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Eileen Corral	TELEPHONE: (714) 743-8354
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2020

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

FACILITY NAME: RASTEGARI, MAHIN	FACILITY NUMBER: 304313749
	VISIT DATE: 04/29/2020

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LPA reviewed with applicant the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult

LPA Corral emailed and discussed a pamphlet on Lead Exposure with applicant. Applicant was informed about E-Learning Modules which are available at https://ccld.childcarevideos.org. 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

Based on today’s inspection and all documentation provided and reviewed, this facility meets licensing requirements and a license for a Large Family Child Care Home will be issued pending Manager final review and receipt of applicant’s acknowledgement of Licensing Report.

An exit interview was conducted with Applicant Mahin Rastegari. The Facility Evaluation Report was reviewed and read to applicant. Appeal Rights and Appeal Right process were explained and will be provided to the applicant via email. Applicant was informed all appeals must be submitted in writing and received by the licensing office within 15 business days. A Read Receipt Reply was requested from Applicant to acknowledge report and Appeal Rights were received. Applicant will respond to email stating "I have received the Facility Evaluation Report and Appeal Rights, I acknowledge receipt." LIC 809 will also be mailed if those options are not available.

End of Report.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Eileen Corral	TELEPHONE: (714) 743-8354
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2020

LIC809 (FAS) - (06/04)

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