334845544-9-27-2021-10-CC-JSAZ-C79VEC-20210927162207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334845544
Report Date: 09/27/2021
Date Signed: 09/27/2021 04:22:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME:	GHOLIPOOR FAMILY CHILD CARE		FACILITY NUMBER:	334845544
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 8	DATE:	09/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mehrnaz Gholipoor		TIME COMPLETED:	04:36 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	On date and time listed, Licensing Program Analyst (LPA) Jeanette Sanchez and Licensing Program Manager (LPM) Stephanie Hudak arrived at the facility to conduct an annual inspection as well as an evaluation of the facility for an increase in capacity. LPA and LPM toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed: · Normal days and hours of operation are: Mon-Fri, 7am to 6pm · OFF-LIMIT AREAS INCLUDE: All bedrooms, Garage · The facility is operating within the licensed capacity and appropriate ratios · Appropriate supervision provided during this inspection · A working telephone is present and the current number is on file · Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection. · Fireplace is properly screened to prevent access by children · All hazardous items are stored inaccessible to children · Toxins are locked · Weapons are not present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations · Stairs are barricaded - N/A single story home · Clean, safe and age appropriate toys · Current roster on file · Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted · Documentation of fire and disaster drills ARE NOT on file - No drill has been completed since license was issued.

SUPERVISOR'S NAME: Stephanie Hudak	TELEPHONE: (951) 320-2021
LICENSING EVALUATOR NAME: Jeanette Sanchez	TELEPHONE: (951) 255-4577
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GHOLIPOOR FAMILY CHILD CARE	FACILITY NUMBER: 334845544
	VISIT DATE: 09/27/2021

NARRATIVE

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· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Verification of control of property on file
· Children’s records are complete
· Employee’s records are NOT complete: LIC501, LIC508, LIC 9052, Copy of ID, 1st aid/CPR expired 3/17/21, Mandated Reporter Training, MMR, dTap, flu (proof of or declination), Health and Safety
· Mandated Reporter Training NOT completed
· Pediatric CPR and First Aid Card expired on 3/17/21
· Health & Safety Certificate - completed on 6/27/19 - Need lead component
· Resident and/or staff records reviewed on 9/21/21 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
-The LICENSEE Mehrnaz Gholipoor, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

IF NOT CURRENTLY PROVIDING IMS USE THIS: 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

SUPERVISOR'S NAME: Stephanie Hudak	TELEPHONE: (951) 320-2021
LICENSING EVALUATOR NAME: Jeanette Sanchez	TELEPHONE: (951) 255-4577
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GHOLIPOOR FAMILY CHILD CARE	FACILITY NUMBER: 334845544
	VISIT DATE: 09/27/2021

NARRATIVE

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-The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov

-The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov

- LPA discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

- Licensee [or facility representative] was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.

SUPERVISOR'S NAME: Stephanie Hudak	TELEPHONE: (951) 320-2021
LICENSING EVALUATOR NAME: Jeanette Sanchez	TELEPHONE: (951) 255-4577
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GHOLIPOOR FAMILY CHILD CARE	FACILITY NUMBER: 334845544
	VISIT DATE: 09/27/2021

NARRATIVE

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There are no deficiencies at this time. Technical Assistance and Technical Violations were issued.

Once all corrections have been made, with proof sent to licensing, the application for a Large Family Child Care Home will be submitted for approval with a maximum capacity of 12, or 14 with parent notification. As agreed upon by the licensee, all corrections are due within 30 days. If not received within 30 days from the date of this report, the application may be withdrawn and the license will remain a Small Family Child Care Home.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Exit interview conducted and report was reviewed with the licensee [or facility representative] (include name). A copy of the LIC 857 (Children’s Record Review), LIC 859 (Staff Record Review), and appeal rights were also provided and discussed this date.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Stephanie Hudak	TELEPHONE: (951) 320-2021
LICENSING EVALUATOR NAME: Jeanette Sanchez	TELEPHONE: (951) 255-4577
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

LIC809 (FAS) - (06/04)

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