376626594-11-6-2019-51-CC-RGOU-BHNTXP-20191106140728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376626594
Report Date: 11/06/2019
Date Signed: 11/06/2019 02:07:49 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:	MOUSAVI, MINA FAMILY CHILD CARE		FACILITY NUMBER:	376626594
ADMINISTRATOR:	MINA MOUSAVI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(858) 519-6660
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92127
CAPACITY:	14	CENSUS: 8	DATE:	11/06/2019
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	12:37 PM
MET WITH:	Mina Mousavi		TIME COMPLETED:	02:15 PM

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 Analysts (LPAs) Rajani Goudreau and Martha Malane conducted an unannounced 3-year required inspection. Upon arrival, LPA met with Licensee, Mina Mousavi and proceeded to tour the facility. There were 8 children in care including one infant, along with licensees’ spouse and one staff member. Facility is within ratio and capacity limitations. Licensees spouse assisted in translating visit. Child care operation hours are Monday through Friday from 6:00 a.m. to 6:00 p.m. LPA conducted a tour of the home/outdoor play area to ensure compliance with standards established in CCR, Title 22, Division 12, Chapter 3. Licensee has provided adequate space for the children to eat, sleep and play within the home. The home is kept is kept clean and orderly, with heating and ventilation for safety and comfort. Areas used for child care include: living room, two bedrooms and bathroom located on first story of home, and back yard. Off limits areas of the home include: dining room, kitchen, garage and second story of home. Off limit areas of the home are made securely inaccessible. All cleaning compounds, detergents, medications and other items which could pose a danger to children are stored where they are inaccessible to children and poisons are to be locked away. The fire extinguisher, smoke and carbon monoxide detector meet requirements and are operational. Children’s toys and play equipment are safe and age appropriate. Primary telephone is a cell which is operational. There are no firearms or other weapons in the home, per licensee. Licensee has all appropriate forms posted, per observation. Two gas fire places observed in home, one located in dining room and another located in living room. Fire places in home are securely screened. Stairs are barricaded by the use of a secure gate. There are no bodies of water observed in or outside of the home. LPAs observed a covered non-operable water fountain located in an area in the back yard not used by children. Outdoor play area is fenced and free of hazardous items. LPA advised Licensee to provide direct supervision. Children’s records and roster reviewed and complete. Pediatric CPR and First-Aid certificate are valid through 09/28/21. See LIC809-C continuation page...

SUPERVISOR'S NAME: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Rajani Goudreau	TELEPHONE: (619) 767-2215
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2019

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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: MOUSAVI, MINA FAMILY CHILD CARE	FACILITY NUMBER: 376626594
	VISIT DATE: 11/06/2019

NARRATIVE

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There are no new adults living or working in the home. All adult residents and assistants have criminal record clearance/exemptions and child abuse index clearances. Last disaster drill was conducted on 07/01/19. Licensee and staff have met immunization requirement per SB792. In addition, Licensee have completed the AB1207 Mandated Reported Training on 05/03/19.

LPA discussed the following with licensee: California Megan's Law, www.meganslaw.ca.gov. LPA informed licensee in order to access Child Care Licensing Regulations and Forms to visit the following website: http://ccld.ca.gov. LPA discussed the following with licensee: Child Care Advocates - (916) 654-1541, childcareadvocatesprogram@dss.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

LPA discussed the following with Licensee: reporting suspected child abuse & neglect, maintain children’s records according to regulation, post all required forms, ensure that all adults living or working in home have criminal background clearances to avoid civil penalties, emergency drills conducted every 6 months, unusual incidents and time frames (report within 24 hours of the incident via duty line and within 7 days of the incident via LIC624B), information on SIDS, shaken baby syndrome, lead poisoning effects brochure. LPA informed licensee corporal punishment, smoking, walkers, exersaucers, jumpers and bouncy seats shall never be permitted during day care operation.

Community Care Licensing Duty Line: (619) 767-2248, open Monday through Friday from 8:00AM to 5:00PM. New LPA assigned to facility is Joelle Redding, 619-767-2222, Joelle.Redding@dss.ca.gov.

LPA, Rajani Goudreau updated the following form at time of visit:
· LIC 999: Facility Sketch (to confirm and update the areas that are accessible to the day care children)

No deficiencies issued during today's visit. LPA conducted an exit interview with licensee. LPA discussed and provided the following to licensee: LIC809, LIC809-C, LIC9213-Notice of Site Visit and appeal rights. LPA informed licensee Notice of Site Visit must be posted for 30 days from today's date. LPA observed licensee post notice of site visit prior to exiting facility.

SUPERVISOR'S NAME: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Rajani Goudreau	TELEPHONE: (619) 767-2215
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2019

LIC809 (FAS) - (06/04)

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