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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376625549
Report Date: 08/24/2021
Date Signed: 08/24/2021 05:02:06 PM

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:EDRISAVIFEYAH, MALIHA FAMILY CHILD CAREFACILITY NUMBER:
376625549
ADMINISTRATOR:MALIHA EDRISAVIFEYAHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 705-9138
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:14CENSUS: 12DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Maliha EdrisavifeyahTIME COMPLETED:
05:00 PM
NARRATIVE
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On 8/24/21 Licensing Prorgam Analysts Michael Morales-DeSilvestore and Patrick Ma conducted an unannounced Annual inspection with the Licensee. The 2 story home was toured and inspected to ensure an environment safe for the care and supervision of children. Present were the Licensee, Leyla Peirovisangari (helper), Mohammad Edrisavifeyah (brother) and 12 day care children (2 infants and 10 preschool age children. The fire extinguisher, smoke detector, and carbon monoxide detector meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. There are no bodies of water on the property. Licensee states that there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. First Aid and CPR certifications expire on 09/21/21. Licensee has required immunizations. Licensee is exempt from Mandated Reporter Training as their Primary language is Farsi. Facility needs to update Children's roster to include all currently enrolled children and must maintain this form for 3 years. Facility needs to update children's files, See LIC809D.

Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include Living room and bathroom 1. Off limits areas include rest of house and are inaccessible through use of locked doors and baby gates. The licensee has sufficient toys and equipment available. The home has a fenced backyard available for outdoor activities.

LPA's reviewed new safe sleep laws and regulations with the Licensee.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Michael Morales-DeSilvestoreTELEPHONE: (619) 767-2208
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: EDRISAVIFEYAH, MALIHA FAMILY CHILD CARE
FACILITY NUMBER: 376625549
VISIT DATE: 08/24/2021
NARRATIVE
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Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, ensure that all adults living or working in the home have criminal background clearances to avoid civil penalties associated with this requirement; corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

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.

The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.

See LIC809D for Deficiencies.

LPA provided notice of site visit and observed it being posted at the facility.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Michael Morales-DeSilvestoreTELEPHONE: (619) 767-2208
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: EDRISAVIFEYAH, MALIHA FAMILY CHILD CARE
FACILITY NUMBER: 376625549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2021
Section Cited

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1596.841 Current roster of children provided care in facility required
Each child day care facility shall maintain a current roster of children who are provided care in the facility...
This requirement is not met as evidenced by:
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Based on observation and file review, the licensee had 12 children in care and only had 8 children enrolled on their Childrens Roster which poses a potential health and safety risk to persons in care.
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Type B
10/07/2021
Section Cited

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102417 Operation of a Family Child Care Home(g)(7)
...maintained for each child and shall include...the parent's authorization for the licensee or registrant to consent to emergency medical care.
This requirement is not met as evidenced by:
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Based on file review, the licensee did not have Consent for Emergency Medical Treatment in all of her childrens files which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Michael Morales-DeSilvestoreTELEPHONE: (619) 767-2208
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: EDRISAVIFEYAH, MALIHA FAMILY CHILD CARE
FACILITY NUMBER: 376625549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2021
Section Cited

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102416.1(a)(10)
Personnel records shall be maintained on each employee...
A signed and dated copy of the Notice of Employee Rights.
This requirement was not met as evidenced by:
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Based on file review, the licensee did not have employee records on file for staf f#1 which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Michael Morales-DeSilvestoreTELEPHONE: (619) 767-2208
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4