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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623672
Report Date: 12/11/2020
Date Signed: 12/11/2020 12:50:30 PM

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:NABI ZADEH, SOUSAN & AKHAVAN, ROKAIFACILITY NUMBER:
343623672
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: DATE:
12/11/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sousan NabiZadeh & Rokai AkhavanTIME COMPLETED:
01:00 PM
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NOTE: Due to COVID19 pandemic and DPH guidelines on stay at home orders, a Tele-visit via FaceTime is being conducted. On Friday, December 11, 2020, approximately at 12:30 PM, Licensing Program Analyst (LPA) Amanda Blesi conducted a Case Management tele-inspection for the purpose of increasing the capacity from 8 to 14 children. During the tele-inspection there were 5 children supervised by Licensee and her spouse. The Fire Safety Clearance has been granted by Sacramento County Department of Community Development Buildings Permit and Inspection on 12/10/2020. With the help of Licensee, a health and safety inspection of all areas accessible to children was conducted. The Off-limits areas include children's bedrooms. Licensee acknowledged that children may never enter these off-limit areas. Current CPR/First Aid certificates (expires: 07/2021), posted License, Parent's Rights, Emergency Disaster Plan, Roster of the enrolled children, and Fire Drill Log are all being maintained by the Licensee. LPA also observed recommended COVID19 posters. Hazardous items were stored inaccessible to children in care. Licensee stated there are no weapons in the home. Fire extinguisher (2A10BC), carbon monoxide and smoke detector meet regulation. Toys appear to be safe. The backyard is fenced. The Licensee understands that in unfenced areas 100% supervision of children is required. There are no bodies of water on the premises. Licensee understands that prior to making alterations or additions to the home or grounds, the licensee shall notify the Department of the proposed changes. In the areas that were evaluated, no deficiencies were observed at the time of the tele-visit.
Capacity increase is approved as of today, 12/11/2020. The facility is licensed to serve a MAX. CAP (WHEN THERE IS AN ASSISTANT PRESENT): 12 - NO MORE THAN 4 INFANTS. CAP 14 - NO MORE THAN 3 INFANTS. 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.
This report (LIC809) and a Notice of Site Visit (LIC9213) will be delivered to the Licensee electronically via email.
Acknowledgement of delivery will constitute acknowledgement of the report in lieu of a signature.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2020
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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