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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404637
Report Date: 05/22/2019
Date Signed: 05/22/2019 04:42:03 PM

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:SHEHABI, FARIDOKHTFACILITY NUMBER:
434404637
ADMINISTRATOR:FARIDOKHT SHEHABIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 260-2561
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:14CENSUS: 10DATE:
05/22/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Faridokht ShehabiTIME COMPLETED:
05:00 PM
NARRATIVE
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On 05/22/19 at 1:30 PM Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Annual Inspection at Faridokht Shehabi's family day care. Licensee, Faridokht (also known as Faye) was not present at home and LPA was greeted by Helpers, Hengameh Sefati and Mahboobeh Firoozmanesh. LPA explained the purpose of today's inspection and Helpers stated that Faye stepped out for shopping just a little while back. Also present in the home were 10 day care children - three infants, seven preschool age. Facility is in compliance with required ratios today. Days and hours of operation are Monday - Friday from 8:00 AM to 6:00 PM. Adults who are over the age of 18 and reside in the home is only the Licensee.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Last fire/disaster drill was completed on 05/06/19. All required postings were observed and complete.

LPA toured the indoor and outdoor areas of the home during today's inspection:
INDOOR SPACE: The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children in the home. LPA observed a container of cleaning powder in the children restroom placed in the cabinet under the sink. There was no child proof latch or lock on the cabinet, making the poisons accessible to them. Furniture and equipment, such as cribs, mats, feeding chairs, and tables were age appropriate and in good condition. There were no baby walkers or bouncers observed on the premise during today’s inspection. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters. A fireplace in the Play Room was barricaded by a book shelf. In-Use areas are: Play Room, Restroom downstairs and Garage converted into a storage and supplies room, mostly used by Helpers to store refrigerated food and change diapers. There was a fish aquarium filled with water and live fish in the garage converted storage room. It was placed high on a table and had a top lid cover. Off limit areas in the home are: Kitchen and Entire second floor upstairs, stairs leading to it is fenced off.
OUTDOOR SPACE: The outdoor space used is the front patio and play equipment was observed to be maintained in safe condition and free of hazards. Facility appeared to be free of flies, other insects, and rodents during today’s inspection.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019
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 6
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: SHEHABI, FARIDOKHT
FACILITY NUMBER: 434404637
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2019
Section Cited
HSC
1596.8662(b)(1)
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On or before March 30, 2018, a person who on, January 1, 2018, is a licensed child care provider, administrator, or employee if a licensed child day care facility shall complete the mandated reporter training […] and shall complete renewal […] every two years […]
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LPA provided the web address https://www.mandatedreporterca.com for Licensee to access the required training. BY POC DUE DATE 06/21/19 Licensee and Helpers 1,2 and 4 will complete the training and send a copy of the Certificate of Completion to Licensing Office.
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This requirement is not met as evidenced by: Based on today’s inspection, Licensee and Helpers 1,3 and 4 do not have completed Mandated Reporter Training AB 1207. Licensee stated that she was unaware of this requirement. This poses a potential risk to the children.
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Type B
06/21/2019
Section Cited
HSC
1596.7995
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HEALTH & SAFETY CODE. Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. […]. The day care center shall maintain documentation of the required immunizations.
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BY POC DUE DATE 06/21/19 Licensee will obtain documentation of the required Measles, Pertussis and Influenza immunization for Helpers 1 and 2. A copy of the documentation will be sent to the Licensing Office as proof of correction.
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This requirement is not met as evidenced by: Helpers 1 and 2 have been working at the day care, but do not have documentation that they are immunized against Measles, Pertussis and Influenza. This poses a potential risk to the health and safety of children 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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: SHEHABI, FARIDOKHT
FACILITY NUMBER: 434404637
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2019
Section Cited
CCR
102369(b)(9)
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Licensees and any adult in the home, shall provide evidence of a current tuberculosis clearance, performed and signed by a physician not more than one year old. This requirement is not met as evidenced by:
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BY POC DUE DATE, Licensee agreed to obtain evidence of Helpers 1, 2 and 3 Tuberculosis clearance that is not more than 1 year old. A copy of the clearance will be sent to Licensing Office.
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Per LPA's review of files, Helpers 1, 2 and 3 do not tuberculosis clearances on file. This poses a potential risk to the health and safety of children 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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: SHEHABI, FARIDOKHT
FACILITY NUMBER: 434404637
VISIT DATE: 05/22/2019
NARRATIVE
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LPA observed a fully charged 3A40BC fire extinguisher and working smoke / carbon monoxide detectors,. The Licensee states that she does not have any weapons in the home.

All ten children's files reviewed and included records of receipt for Parents' Rights and Immunization records.

Licensee and four Helpers files were reviewed and all had Criminal Record and Child Abuse Index Clearance or Exemption, Statement Acknowledging Requirement to Report Suspected Child Abuse. Some Helpers were missing TB clearances and immunization for Measles, Pertussis and Influenza. Licensee and all Helpers did not have required Mandated Reporter Training per AB1207. Licensee stated she was unaware of the requirement. LPA advised the Licensee of the required "Mandated Reporter" training for CA Child Care Providers that all Licensees and staff are required to complete as of January 1, 2018. The website for the online training is: http://www.mandatedreporterca.com/training/childcare.htm.
Helper 1 certifications for CPR and First Aid are current and expire December 2020. Licensee stated she will renew her CPR certification and also for Helpers 3 and 4. Since Helper 2 works part-time and comes to work with children for music/art activities once a week, she is not required to do CPR First Aid.

LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes in contact with or provide 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.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during 80% of the operating hours of the day care and ensure that the children are supervised at all times. The Licensee understands her capacity options and that she cannot have more than 14 children in the home at any time with at least two qualified adults present. Licensee also understands that she must comply with the ratio and capacity requirements of the Family Child Care Home license whenever she or a qualified adult is alone with the children. The Licensee states that she does not transport children.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: SHEHABI, FARIDOKHT
FACILITY NUMBER: 434404637
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2019
Section Cited
CCR
102417(g)(4)
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Operation of a Family Child Care Home: Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
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Type A citation was issued. Licensee removed the cleaning powder immedaitely and this citation was cleared during the inspection today. Licensee stated she will ensure that all poisons are stored inaccessible to children.
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LPA observed a container of cleaning powder stored in the cabinet under the sink in the restroom used by children. Cabinet did not have a latch or lock. This poses an immediate risk to the health and safety of children in care.
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Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to the parent of children enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.
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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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: SHEHABI, FARIDOKHT
FACILITY NUMBER: 434404637
VISIT DATE: 05/22/2019
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. The Licensee stated that she currently does not have any children in care who requires IMS. 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.

LPA provided a copy of the Lead Poisoning Information Pamphlet to the Licensee and advised that all parents be given a copy of the same. Licensee should also keep a log confirming parents received this pamphlet.

Website links for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

childcareadvocatesprogram@dss.ca.gov

In the areas that were evaluated, regulatory violations were observed at the time of the visit. Exit Interview was conducted, where this report, the citations, plan of corrections, and appeal rights were reviewed and discussed with Licensee. Citations are issued on 809-D pages of this report.
LPA reminded Licensee that failure to correct deficiencies by Plan of Correction Due Date may result in penalties of $100 per day per violation.

Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to the parent of children enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.

A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED NEAR THE FRONT ENTRANCE TO THE HOME FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019
LIC809 (FAS) - (06/04)
Page: 6 of 6