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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408192
Report Date: 06/21/2019
Date Signed: 06/21/2019 04:02:27 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:KAENI, SIMINFACILITY NUMBER:
434408192
ADMINISTRATOR:KAENI, SIMINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 871-2635
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:14CENSUS: 8DATE:
06/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Simin KaeniTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Rangel, conducted an annual random inspection. LPA met with Licensee, Simin Kaeni, and explained the nature of today's inspection. Present in the home are licensee and licensee's husband, helper, and 8 children including 3 infants, and 5 preschool age.

Days and hours of operation are Monday thru Friday from 7:30 AM to 5:30 PM. There are two adults living in the home: licensee and her husband. Licensee, has current CPR and First Aid certification that expires 9/26/19. Licensee carries daycare insurance under DCI with an expiration date of January 27th 2020.

LPA toured the indoor and outdoor areas of the home. The home is clean and orderly. LPA observed a fully charged 3A40BC fire extinguisher, working smoke and carbon monoxide detector, barricaded fireplace, wood stove, and fenced backyard. The home has a swimming pool that meets regulations. Off limit areas in the home: garage. Off limit areas outside the home: swimming pool area, and right side yard. Licensee states there are no weapons in the home. Medicines, cleaning compounds, and other similar items are stored inaccessible to children. LPA informed licensee that any poisons need to be locked. LPA observed a current children's roster. LPA observed sufficient and safe toys, materials, and play equipment for the children.

During the inspection, LPA reviewed 5 children's files.


REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 06/21/2019):
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
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 3
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: KAENI, SIMIN
FACILITY NUMBER: 434408192
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2019
Section Cited
HSC
1597.622
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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 was not met as evidenced by the Licesee not being able to show proof of vaccines for her and her staff. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Licensee stated that she will submit proof of immunizations for her and her helper(s) to CCL by POC due date of 7/26/19.
Type B
07/26/2019
Section Cited
CCR
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 of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a) and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
This requirement was not met as evidenced by the Licensee and hwelpers not being able to show proof of completion of mandated reporter training. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Licensee stated the she and helpers will complete the mandated reporter training for AB 1207 and submit proof of completion of training to CCL by POC due date of 7/26/19.
Type B
06/28/2019
Section Cited
HSC
102417g9a1
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Operation of Family Day Care Home: The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home. This requirement was not met as evidenced by the Licensee not being able to show proof of completion of a fire drill since 11/2018. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Licensee stated that she will complete a fire drill and send proof to CCL by POC due date 6/28/19.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: KAENI, SIMIN
FACILITY NUMBER: 434408192
VISIT DATE: 06/21/2019
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 06/21/2019):

A review of staff records on 6/4/19 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA conducted an exit interview with the Licensee prior to the conclusion of today's inspection and advised the Licensee of the required "mandated reporter" training for CA Child Care Workers for AB 1207 that all Licensees and staff are required to complete every two years as of January 1, 2018. The website for the online training is: http://www.mandatedreporterca.com/training/childcare.htm

LPA reminded Licensee of the new Immunization Regulations for Senate Bill (SB) 792, the requirement that all individuals working or volunteering at a licensed Child Care facility must have vaccinations against, Pertussis, Measles and Influenza. LPA advised the licensee that they can sign a declaration to be exempt from the influenza vaccinations however; Pertussis and Measles are not exemptible.

Periodic information releases accessible by signing up at: www.myccl.ca.gov

Effect of Lead Exposure handout dated 1/20/19 given during today’s inspection. Per Assembly Bill (AB 2370), written information regarding lead exposure needs to be given out to enrolling and re-enrolling parents or guardians.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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. Licensee stated that she will send IMS plan to CCL by 6/28/19.

As a result of this inspection, deficiencies cited on the following page. Appeal rights printed and reviewed.



NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3