430755034-4-24-2023-07-CC-ALOZ-CR7SL9-20230424135757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430755034
Report Date: 04/24/2023
Date Signed: 04/24/2023 01:58:11 PM

Document Has Been Signed on 04/24/2023 01:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	KHATAMI, FARIDEH		FACILITY NUMBER:	430755034
ADMINISTRATOR:	KHATAMI, FARIDEH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 559-4986
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	14	CENSUS: 0	DATE:	04/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Farideh Khatami		TIME COMPLETED:	02:10 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) Ashley Lopez and Marilou Monico met with Licensee Farideh Khatami, for an unannounced Required – 1-year annual inspection. LPAs were granted access to the home by the Licensee. LPAs did not observe any children in the home during today's inspection. Licensee indicated that there are 2 children enrolled in the day care, but does not have a current roster. LPAs observed the required postings, including the facility license. Days and hours of operation are Monday - Friday from 7AM-5PM. The adults residing in the home are: Licensee and Licensee's daughter Vida. Licensee does not have a current Fire/Disaster drill log. Licensee states that she does not have liability insurance for the day care. Licensee has current CPR and First Aid certifications expiration: 3/2025 . Licensee is missing the required vaccines (MMR, Tdap, & flu). LPAs reviewed 1 child's file and the file is missing immunizations. C2 that is enrolled is missing all documents. LPAs toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home (408) 559-4986. The home is clean and orderly, and safe for the day care children. There are safe & age-appropriate toys, play equipment, and materials for the children in the home. There are no stairs inside the home. LPAs did not observe any wall heaters inside the home. Off limit areas inside the home: garage, 2 bedrooms, and hallway bathroom. Off limit areas outside the home: left and right sides of backyard.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Ashley Lopez	TELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHATAMI, FARIDEH	FACILITY NUMBER: 430755034
	VISIT DATE: 04/24/2023

NARRATIVE

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LPAs observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does not have any pets or weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee states that there are no poisons in the home. Licensee states that she does not administer any medications to the day care children. Licensee has a first aid kit in the home. Licensee states that nobody smokes, and she understands that smoking is prohibited in the home.

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

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity/ratio options and she understands that she cannot have more than 14 children present in the home. Licensee states that a child will be isolated on the other side of the room if necessary due to illness or communicable disease. Licensee states that she does not transport any day care children. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Ashley Lopez	TELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHATAMI, FARIDEH	FACILITY NUMBER: 430755034
	VISIT DATE: 04/24/2023

NARRATIVE

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LPAs discussed the safe sleep regulations with the Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

Exit interview conducted and report was reviewed with the Licensee, Farideh Khatami.
Deficiencies were issued during today's inspection. A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Ashley Lopez	TELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/24/2023 01:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHATAMI, FARIDEH	FACILITY NUMBER: 430755034
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee does not have current Fire Drill Log which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Licensee stated she will submit a current Fire Drill Log to licensing by 5/5/23.

Type B

Section Cited

CCR

102418(a)

Administration of Child Day Care Licensing

Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 children's records, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Licensee stated she will submit copies of the 2 children's immunization records to licensing by 5/5/23.

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Ashley Lopez	TELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 04/24/2023 01:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHATAMI, FARIDEH	FACILITY NUMBER: 430755034
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee does not have proof of immunizations (measles, pertussis, flu, and TB) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Licensee stated she will submit proof of immunizations (measles, pertussis, flu, and TB) to licensing by 5/5/23.

Type B

Section Cited

CCR

102417(g)(8)

Operation of A Family Child Care Home

(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee does not have current children's roster which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Licensee stated she will submit a current Children's roster to licensing by 5/5/23.

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Ashley Lopez	TELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

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