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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623379
Report Date: 12/19/2019
Date Signed: 12/19/2019 10:35:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:GOODARZI, AZARDOKHTFACILITY NUMBER:
343623379
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
12/19/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Azardokht GoodarziTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Kelly Ferrara met with applicant Azardokht Goodarzi (Azar) for the purpose of a pre-licensing inspection. LPA toured the interior and exterior of the three bedroom, two and a half bathroom home. The home was inspected for safety, comfort, cleanliness, and heating and ventilation. LPA inspected for poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Off-limit areas will consist of: Garage and entire upstairs. Applicant understands that children may never enter these off-limit areas. Applicant acknowledges she is required to notify licensing prior to making changes to off-limit areas so that they may be inspected for safety. Applicant stated she plans to operate Monday- Friday 7 AM- 6 PM.

Applicant lives with her spouse and children in the home. Adults living in the home have received a criminal record clearance and are associated to the facility. Individuals who are 18 years of age or older living in the home or frequent visitors must obtain a criminal record clearance. Failure to receive a background clearance will result in a civil penalty.

LPA observed a functioning smoke and carbon monoxide detector, and a 2A-10BC fire extinguisher to meet regulations. Hazardous cleaning products and chemicals, knives, and medications are all stored inaccessible to children. Applicant understands that poisons such as weed killer and Drano must be locked. The backyard is fenced and LPA advised applicant that in areas that are not fenced, 100% supervision must be maintained at all times. There are no bodies of water or firearms in the home.

The applicant owns the home and LPA observed a recent mortgage statement. Applicant is aware that she will need to have parents sign an affidavit stating that she does not have liability insurance at this time. The applicant has completed the preventative health and safety training which includes the training on nutrition by an EMSA certified instructor as well as the Mandated Reporter training. Applicant understands that this training must be updated every two years online at www.mandatedreporterca.com, AB1207.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: GOODARZI, AZARDOKHT
FACILITY NUMBER: 343623379
VISIT DATE: 12/19/2019
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LPA advised the applicant that any assistant that is hired must be over the age of 14 and is also required to have immunization records on file including Measles, Mumps, Rubella and Pertussis, take the Mandated Reporter training, and be fingerprint cleared and associated to the facility if over 18. The flu shot is also needed annually between September 1st and December 1st of each year or a declination letter to opt out of the shot. The applicant provided proof of her immunizations.

LPA discussed Type A and Type B citations, Zero Tolerance, and Civil Penalties with the applicant. LPA discussed open door policy, supervision, fire drills, children’s personal rights, and the smoking prohibition with the applicant. LPA discussed ratio and capacity limitations with applicant. Applicant stated she does not plan to transport children at this time. LPA advised that all proper restraints must be used when transporting children in her vehicle. A current roster of children enrolled must be available and maintained for a period of three years, even after children are no longer in care. Annual fees must be paid promptly and by the due date or late fees will be assessed or the license will be terminated.

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.

LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the applicant can request to be added to the distribution list to receive Quarterly Updates. LPA provided form LIC 311D and discussed the required forms for children's records, employee records, and forms required to be kept on file at the facility. LPA provided the Licensing Agency website (WWW.CCLD.CA.GOV), so that the applicant may obtain updated licensing information, regulations, and forms. LPA gave the applicant a hand out for information on Lead Exposure and Safe Sleep

LPA recommends the home to be licensed as of today's date, December 19th, 2019. The home will be licensed to serve up to 8 children, two (2) of which must be school age children, one at least age 6 years of age, one enrolled in kindergarten and no more than two (2) may be infants; or 6 children, three (3) of which may be infants; or 4 infants only. Infants are children under the age of two years old. A copy of this report was given to the applicant to keep on file at the facility.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019
LIC809 (FAS) - (06/04)
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