434404637-1-21-2022-07-CC-AMOS-CAUW4H-20220120155735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434404637
Report Date: 01/20/2022
Date Signed: 01/21/2022 08:55:31 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:	SHEHABI, FARIDOKHT		FACILITY NUMBER:	434404637
ADMINISTRATOR:	FARIDOKHT SHEHABI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 260-2561
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	14	CENSUS: 4	DATE:	01/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Faye Shehabi		TIME COMPLETED:	04:20 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 Analyst (LPA) Anna Morales conducted an ANNUAL REQUIRED inspection. LPA was greeted by Licensee Faye Shehabi and her assistant Hengameh Sefati. There were two infants ( over twelve months of age) and one toddler and one preschool aged children. The children were taking their naps during the inspection. Hours of operation are Monday through Friday, 8:00am through 6:00pm. Licensee stated that she is the only adult that that reside in the home. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire drill is reported as being conducted on 08/1/2022. LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee’s has a working telephone in the home. LPA observed sufficient materials in the Play Room, toys, and play equipment for the day care children. The Licensee has also converted the garage into a storage and supplies room, mostly used by staff to store refrigerated food and change diapers. The home is clean, orderly and safe for the day care children. LPA observed barricaded fire place and staircase. Off limit areas inside Licensee's home: kitchen, the entire upstairs (bedrooms and bathrooms). Off limit areas outside the home: back yard. The children utilize the front courtyard and outer area with supervision at all times.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

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

FACILITY NAME: SHEHABI, FARIDOKHT	FACILITY NUMBER: 434404637
	VISIT DATE: 01/20/2022

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. Licensees stated that she does not take care of any children who are ill. 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. Licensee have an area where sick children can be isolated from the others until parent pick-up.

Licensee and her assistant's Mandated Reporter Training (AB1207)expired on 6/2021. This training is being waived as English is their second language. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

Four of the children's files was reviewed during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization Records (PM286).

Licensee and one staff files were reviewed for the following records: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Licensee does not have a current First Aid/CPR on file. It expired on 6/2021.

LPA 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.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

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

FACILITY NAME: SHEHABI, FARIDOKHT	FACILITY NUMBER: 434404637
	VISIT DATE: 01/20/2022

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LPA discussed and left a copy of Pin 20-24-CCP, RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT. Discussed that all INFANTS UP TO 12 MONTHS OF AGE MUST HAVE AN INDIVIDUAL INFANT SLEEPING PLAN (LIC9227) ON FILE, WHICH WILL DOCUMENT THE INFANTS SLEEPING HABITS, USUAL SLEEPING ENVIRONMENT, AND THE INFANT ROLLING ABILITIES. PROVIDERS MUST CONDUCT CHECKS EVERY 15 MINUTES ON SLEEPING INFANTS (UP TO TWO YEARS OLD). Child Care Licensing Safe Sleep web page at:https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA discussed the requirements of AB 633 with the Licensee and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Exit Interview was conducted with Licensee. Deficiency is being cited based on the LPA's observations, interviews conducted and records reviewed in accordance with the California Code of Regulations Title 22.

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

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/inspection-process

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: 01/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. 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 current PEDIATRIC FIRST AID/CPR . The Licensee and her assistant Pediatric First Aid/CPR expired in 6/2021,which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2022
	Plan of Correction
1 2 3 4	Licensee stated that she will send a copy to CCL by the POC date, 2/21/22

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC809 (FAS) - (06/04)

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