344500131-11-14-2019-53-CC-FDIZ-BHWPGM-20191114101835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 344500131
Report Date: 11/14/2019
Date Signed: 11/14/2019 10:18:43 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:	ZARRABI, MISTY ANN		FACILITY NUMBER:	344500131
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	11/14/2019
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Misty Ann Zarrabi		TIME COMPLETED:	10:30 AM

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	Licensing Program Analyst (LPA) Fabiola Diaz met with Applicant Misty Ann Zarrabi for a Change of Location inspection. LPA toured all areas of the one story home. The home consists of 4 bedrooms, three bathrooms, laundry room, garage, 2 living rooms, kitchen area, play room, and a fenced back yard. Off limit areas include: all bedrooms, garage, and laundry room. LPA observed no bodies of water on the property. Toxins and dangerous items were found inaccessible. The smoke alarm and fire extinguisher meet Title 22 regulations. LPA observed an operating carbon monoxide detector. Applicant acknowledges that 100% supervision must be maintained in unfenced areas of the front yard. LPA observed MMR and TDap immunization records for Applicant. Applicant is currently enrolled to take the Preventative Health and Safety Training on 12/07/19. LPA verified a current CPR/First Aid certification. All adults in the home have criminal record clearances. Applicant has completed the required AB1207 Mandated Reporter training. Applicant understands that the training must be completed once every two years, and training is accessible at www.mandatedreporterca.com. 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. Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes. [Report continues on LIC809-C]

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019

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: ZARRABI, MISTY ANN	FACILITY NUMBER: 344500131
	VISIT DATE: 11/14/2019

NARRATIVE

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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 licensee can request to be added to the distribution list to receive Quarterly Updates.
LPA provided and discussed the Safe Sleep in Child Care brochure and the Effects of Lead Brochure.

Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Applicant understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area. Applicant understands that children’s records are to be maintained according to Title 22 regulations, and be accessible to licensing for up to three years.
This facility evaluation report was reviewed and discussed with the applicant. An exit interview was conducted. LIC 311D, records, postings, and reporting requirements were discussed.

Effective November 14, 2019, LPA is granting a small family child care provisional license for 90 days for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2. Provisional license expires on 02/14/2019. Upon completion of Preventative Health and Safety course a regular License will be granted.

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019

LIC809 (FAS) - (06/04)

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