376100555-10-26-2020-51-CC-SSIO-BURNBC-20201026101856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376100555
Report Date: 10/26/2020
Date Signed: 10/26/2020 10:20:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	ESMATI, KHATIMA & AZIM, MOHAMMAD FAMILY CHILD CARE		FACILITY NUMBER:	376100555
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 2	DATE:	10/26/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Khatima Esmati		TIME COMPLETED:	10:25 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	On October 26, 2020 at 9:00am, Licensing Program Analyst (LPA) Selina Siao conducted a scheduled change of location pre licensing. LPA conducted a virtual inspection via Face Time with applicant Khatima Esmati due to COVID-19. Present at the home is applicant Khatima Esmati and her two daughters. The 3 bedroom, 2.5 bath, 2 stories house was toured and inspected to ensure an environment safe for the care and supervision of children. The home has a fully charged fire extinguisher, smoke and carbon monoxide detector that meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children during the inspection. Applicant Khatima Esmati stated that the home doesn't have any weapon or bodies of water. Applicants have an EMSA approved pediatric CPR and First Aid card that are current due to expire on 09/26/2022 and they both completed the 8 hours preventative health practice course on 12/11/2016 and completed the lead poisoning prevention course on 10/21/2020. Applicants primary language is Farsi therefore they are not required to take the mandated child abuse training at this time. A review of the application and records on this date indicates that applicant and her husband Mohammad Azim are the current adult residents at the home with the require TB clearances, immunizations and caregiver background check clearances. Applicant Mohammad Azim owns the property and has provided a copy of the grant deed as proof. Applicant will be using the following areas for childcare: living room, dining room, family room, kitchen and 1/2 bathroom located downstairs. The home has a fireplace that is blocked off with a fireplace screen. Off limit areas includes upstairs and there is a secured safety gate to prevent access. The attached garage is also off limit and is inaccessible with a doorknob cover. Outdoor area will be the fenced backyard and supervision is required when children are playing outside. Applicant was reminded of requirements for children’s records, facility roster, child Cont. on next page LIC809C

SUPERVISOR'S NAME: Monica Cuddy	TELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina Siao	TELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: ESMATI, KHATIMA & AZIM, MOHAMMAD FAMILY CHILD CARE	FACILITY NUMBER: 376100555
	VISIT DATE: 10/26/2020

NARRATIVE

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abuse and unusual incident reporting, immunizations, adults living or working in the home and associated civil penalties of $100 per day, car seat law, shaken baby syndrome and SIDS. Applicant was reminded that corporal punishment, smoking, baby walkers, exersaucers, bouncy seats and baby jumpers are not allowed in day care. The ABC’S of Safe Sleep: Sleep is Safest: Alone, on their Back in an empty Crib on a firm mattress.

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

Applicant shall comply with all regulations and laws governing family childcare homes and be financially secure to operate a family childcare home for children.

Child Care Providers can now sign up for Quarterly Updates and PINS through the DSS website at www.ccld.ca.gov . LPA discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

Applicant has completed and submitted the family childcare self-certificate checklist and the COVID-19 self-assessment guide. All required postings are posted at the home including the COVID-19 related postings.

The following correction is needed within 10 days prior to granting a license:

LPA needs to inspect one of the upstairs bedrooms as the door is locked and applicant stated that someone will open that door today.

Analyst read the report to applicant during the tele-inspection. A copy of the report will be e-mailed to applicant’s husband Mohammad Azim and she was advised that acknowledgement of the receipt of the report is to be received from applicant within twenty-four hours.

SUPERVISOR'S NAME: Monica Cuddy	TELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina Siao	TELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020

LIC809 (FAS) - (06/04)

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