434401704-10-21-2022-52-CC-CURE-CKEVS7-20221021164101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434401704
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:42:02 PM

Document Has Been Signed on 10/21/2022 04:42 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	FATHI, SETARE		FACILITY NUMBER:	434401704
ADMINISTRATOR:	FATHI, SETARE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 964-8677
CITY:	LOS ALTOS	STATE: CA	ZIP CODE:	94024
CAPACITY:	14	CENSUS: 6	DATE:	10/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Setare Fathi		TIME COMPLETED:	01:30 PM

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On 10/21/2022 at 9:15am Licensing Program Analyst (LPA) Christina Uribe, met with licensee Setare Fathi for an UNANNOUNCED ANNUAL INSPECTION. Present for the inspection were 6 daycare children (between 2-5 years of age) and 3 fingerprint cleared assistants. The licensee is within ratio today. Upon arrival LPA provided licensee a copy of the Entrance Checklist (LIC 126). The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday-Friday 9:00am-2:00pm.

The main house is off limits to daycare and the on limit areas is the Junior Additional Dwelling Unit (JADU), front yard and back yard. LPA observed the home to be neat and clean with central heating and ventilation for safety and comfort. All on/off-limit areas are consistent with the facility's pre-licensing reports.

The OFF-LIMIT AREAS are all of the rooms in the main house and are inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS are the two rooms (which are set up as a classroom) and bathroom of the JADU.

The facility’s outdoor play space is located in the front and backyard of the home. The play structure, equipment, and fence are all in safe condition free from hazards which could pose a risk to children in care. There is ample shade available and gates are locked at all times while children are in the yard. There is a pool in the backyard which is located to the far left of the yard, away from where the children play and is fully fenced to meet compliance.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, carbon monoxide, telephone and fully stocked first aid kit. Per licensee, there are no firearms on the premises. There are 4 chickens, 2 cats, 4 cockateels, and a fish tank which is located inside of the classroom.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina Uribe	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: FATHI, SETARE	FACILITY NUMBER: 434401704
	VISIT DATE: 10/21/2022

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The licensee completed the Health and Safety training, CPR/First Aid certification expires on 04/17/23. The licensee is in compliance with the immunization laws and has completed the mandated reporter training on 05/27/21.

The licensee conducts and documents fire and disaster drills which are performed at least every six months and the last conducted drill was on 10/21/22. While LPA Uribe tested the smoke alarm, the facility used that opportunity to perform a fire drill. All required forms are posted and visible for public review.

LPA Uribe reviewed 6 children’s files and personnel records for licensee and all staff. There is a current roster available for review. The facility does have liability insurance which is valid through 11/01/2022. Staff interview also conducted and documented.

Incidental Medical Services (IMS) policy was discussed and the facility does not have any children with the need for medication to be kept at the facility at this time. 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.

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.

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.

Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina Uribe	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: FATHI, SETARE	FACILITY NUMBER: 434401704
	VISIT DATE: 10/21/2022

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No Deficiencies CIted. Only Technical Violations Cited During Today's Inspection: Please see attached pages for additional information.

Technical Violation: Two assistants were missing proof of MMR immunization in their file.
Technical Violation: One assistant only had a Mandated Reporter Certificate for general training not for Child Care Providers (AB 1207).

A notice of site visit was given and must remain posted for 30 days. Appeal rights were given and reviewed. Exit interview conducted and report was reviewed with the licensee, Setare Fathi.

Page 3 of 3 ***End of Report***

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina Uribe	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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