434404138-8-3-2021-07-CC-PHEZ-C5JP8X-20210803110615

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434404138
Report Date: 08/03/2021
Date Signed: 08/03/2021 11:06:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	TAYEBI, HAJAR		FACILITY NUMBER:	434404138
ADMINISTRATOR:	HAJAR TAYEBI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 261-8986
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	14	CENSUS:	DATE:	08/03/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Hajar Tayebi		TIME COMPLETED:	11:20 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	Licensing Program Analyst (LPA) Pete Hernandez conducted an Required 1 Year visit to the home today. LPA met with Hajar Tayebi who was caring for five (5) napping children (one infant and 4 preschool aged) and explained the purpose for today’s inspection. Also Present was her adult son Hooman Tayebi and her assistant Darlene Bolivar her adult helper. Licensee is the homeowner and resides in the house with her two adult children. They each have fingerprint clearance. Days and hours of operation are Monday through Friday 8:00 AM to 5:00 PM. Licensee's CPR and First Aid card is current and expires on 06/2022. LPA toured the indoor and outdoor (on and off limits) areas of the home. LPA observed a fire drill log with the last fire drill being conducted in 06/2021. LPA reviewed a current facility roster. The Licensee has a working telephone in the home and the phone number is (408) 261-8986. LPA observed sufficient materials, toys, and play equipment for the day care children. Off limit areas inside the home: master bedroom, master bath, son's bedroom, daughter's bedroom and hallway bathroom. Off limit areas outside the home: gated right side of the backyard and the storage room. The home is clean, orderly, and safe for the day care children. LPA observed a barricaded fire place in the home. LPA observed no stairs in the home. LPA observed a fully charged 2A10BC fire extinguisher. There is a working smoke & carbon monoxide detector. The backyard is fenced. License stated that when outside the children are supervised by herself and at least one other helper. LPA observed no bodies of water. The Licensee states that she does not have any firearms or other weapons in the home. All poisons, detergents, cleaning supplies, medications, and other similar items are inaccessible to children. LPA reviewed 4 children's files and observed the required documentation. REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 078/03/2021):

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

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

FACILITY NAME: TAYEBI, HAJAR	FACILITY NUMBER: 434404138
	VISIT DATE: 08/03/2021

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (REPORT DATED 08/03/2021):
Licensee has the required immunization's against Pertussis, Measles and influenza on file for herself and her assistant Darlene. Supervision of children was discussed with the Licensee. Licensee stated she is present in the home 100 percent of the hours the day care is in operation and ensures that the children are supervised at all times. The Licensee understands her capacity options. The Licensee stated that she does not transport children via vehicle. Licensee understands the seat belt/car seat laws and that children cannot be left in parked vehicles unattended at any time.

A review of Staff records indicates that all persons that require a caregiver background check have received criminal record and child abuse index clearance or exemption. LPA informed Licensee of the applicable civil penalties for any adult who has not received fingerprint clearances, is not associated to the license and who comes in contact with or provides care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12- month period.

LPA discussed the requirements of AB 633 with the Applicant (or Licensee) and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Applicant (Licensee) understands the requirements.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov. The Mandated Reporter Training (AB1207) can be completed at the website listed, http://www.mandatedreporterca.com English is a second language for both Licensee and Assistant. Mandated Reporter is not required at this time.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

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

FACILITY NAME: TAYEBI, HAJAR	FACILITY NUMBER: 434404138
	VISIT DATE: 08/03/2021

NARRATIVE

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LPA Discussed the Individual Infant Sleep Plan with the Licensee.

Licensee also provided a current copy of the Childrens Roster.

A deficiency NOT is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, An exit interview was conducted,A copy of this report and appeals rights were discussed and left with the Licensee, Tayebi Hajar, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC809 (FAS) - (06/04)

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