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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313904
Report Date: 06/24/2021
Date Signed: 06/24/2021 01:10:43 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:YOUSEFI, P & SADAGHIANPOOR, SFACILITY NUMBER:
304313904
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
06/24/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee Sadaghianpoor SeyedehMania TIME COMPLETED:
01:30 PM
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Licensing Program Analyst’s (LPA) Ketki Desai, conducted an announced in-person Pre-Licensing inspection for a new Small Family Child Care home. LPA met with applicant Ms. S, SeyedehMania who provided a tour of the new home. This is a relocation for the Licensee. Currently she is caring for 1 child only, LPA observed Licensee wearing face mask, and following CDC and Dept of Public Health Guidelines.

A review of the Facility Personnel Report Summary indicates adult resident, who require caregiver background check clearances exemptions is received and is cleared.

Licensee stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. Applicant was reminded if changes to notify the licensing office.

Per Licensee, operation hours will be Monday to Friday, 7.00 AM to 5.30 PM and care and supervision shall be provided to children ages 4 months to three and half years old only ( Mainly Infants and Toddlers)

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a single story home with four bedrooms, two baths, living room, kitchen/dining area, garage, Front, side and backyard

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. The home has central air and heating system.

Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. Licensee states (that there are no poisons on the premises). Licensee was advised that any poisons must be locked with a key or combination lock. (1)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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: YOUSEFI, P & SADAGHIANPOOR, S
FACILITY NUMBER: 304313904
VISIT DATE: 06/24/2021
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Based on the Facility Sketch submitted, areas off limits to children and parents are: Applicant has designated the two bedrooms, one bathroom, living area, kitchen/dining area, partial backyard , side yard, garage and storage area in the backyard as Off-limits areas.

Licensee has two designated rooms for Day care, the door of the Day care is locked during operating hours making the other areas of the home inaccessible and there is a separate entrance to the day care area

There is a fireplace in the living area with a metal barrier installed across, living area is designated as off limit area. The partial backyard has a child safety fencing across, making part of the backyard and side yard inaccessible to children. During the Pre-licensing inspection, LPA observed the doors of the other rooms were closed and locked with a key on the handle.

Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Areas Designated for Day care activities: Licensee has designated two bedrooms, one bathroom and partial backyard for Day care activities. ( Master-bedroom and one bedroom is converted into Day Care areas)

The children shall enter through the side wooden door accessed from the front yard, leading the path to the open backyard and through the sliding glass door into the Day care room. This room has been set up with Day care activities designed mainly for Infants and Toddlers. The second bedroom has cribs this rooms shall be used mainly for infant care, additional infant needs were also observed here. Licensee is aware of ongoing supervision for infants. Licensee has posted the required posters and guidelines are being implemented.

The designated Child Care was observed to have age appropriate toys, educational items. Children shall nap in this area. Older Toddlers shall use soft cushioned blankets with sleeping bags, provided by the parents and are washed weekly or as needed. Young infants shall nap in the cribs. All Infant needs shall be provided by the parents .

Upon entrance through the designated door, applicant shall receive the children here, Due to Pandemic parents are encouraged to stay at the main door where the infants are received. Upon entrance temperatures shall be checked, hands shall be sanitized, and the children shall be guided into the designated day care areas.

COVID-19 guidelines and precautions were discussed with the Licensee. (Page-2)

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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: YOUSEFI, P & SADAGHIANPOOR, S
FACILITY NUMBER: 304313904
VISIT DATE: 06/24/2021
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The bathroom is in the designated day care room itself, it was observed to be safe and free of hazardous items. There are two sinks outside the bathroom and the cabinets underneath were locked .Since the care is mainly provided to Infants and Toddlers, Licensee has a changing area for diapering activity.

OUTDOOR PLAY AREA: Licensee have designated the partial backyard with grassy area for day care activities. There are age appropriate outdoor toys and a small climbing structure for Toddlers. Licensee also has placed awing providing the needed shade during outdoor play. The back yard is fenced with proper flooring.

Per applicant there are no Pets, weapons or ammunition in the home.



Bodies of Water: Licensee has one spa in the back yard. Spa is covered with a durable cover and is locked, it is not easily climbable by children. Spa meets the regulation

There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards.

Licensee states she shall provide Breakfast / Lunch and Snacks to the Toddlers. All Infant needs shall be provided by the parents and the containers shall be labelled and stored accordingly.



Applicants have completed the required Health and Safety with Nutrition and Lead Poisoning component Training and Pediatric First Aid and CPR which expires on 2/23. There are first aid supplies available.

The following was discussed with the applicant:
·Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately.

Civil Penalties will be assessed if not in compliance.
·In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification and a valid criminal record clearance associated to the facility license along with Immunization and TB clearance results on file.
(Page-3)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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: YOUSEFI, P & SADAGHIANPOOR, S
FACILITY NUMBER: 304313904
VISIT DATE: 06/24/2021
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Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
·The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

Applicant was also made aware of the Child Advocacy program so she could receive the updated Quarterly reports and other information in a timely manner. ChildCareAdvocatesProgram@dss.ca.gov

Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.


Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Fire and safety drills must be performed every six months and documented for review by the Department.
Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No smoking, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

UPDATE: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.
The applicant has submitted proof of immunization's.

(Page-4)

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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: YOUSEFI, P & SADAGHIANPOOR, S
FACILITY NUMBER: 304313904
VISIT DATE: 06/24/2021
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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 licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles.



When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization's, Pediatric CPR/First Aid, and mandated reporter training.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. Licensee does have lead training Certificate. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: YOUSEFI, P & SADAGHIANPOOR, S
FACILITY NUMBER: 304313904
VISIT DATE: 06/24/2021
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Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with licensee 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 if 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 to wear a T-shirt and not be too hot or too cold.


OTHER INFORMATION AND FORMS PROVIDED: Capacity Handout for a Small Family Child Care Home

Per Licensee, there are no dual licenses at this address. Licensee's email address was obtained during this inspection. Licensee was advised that email may be public information. Once licensed, Licensee is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

The facility at the time of Pre-licensing is in compliance for a (Small Family Child Care Home) with Title 22 Regulations. License shall be issued after management approval.

Appeal rights were presented and Exit interview was conducted with the Licensee Ms. Sadaghian, Seyedehmania
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC809 (FAS) - (06/04)
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