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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408192
Report Date: 03/04/2020
Date Signed: 03/04/2020 10:45:48 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:KAENI, SIMINFACILITY NUMBER:
434408192
ADMINISTRATOR:KAENI, SIMINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 871-2635
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:14CENSUS: 8DATE:
03/04/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Simin KaeniTIME COMPLETED:
10:45 AM
NARRATIVE
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On 3/4/2020 at 08:20: LPA, Pete Hernandez, arrived for a Required - 1 Year visit. LPA was greeted at the door by Simin Kaeni. LPA explained the purpose of the visit. There were 8 children present at the time of the inspection; one infant and 7 preschoolers. The Licensee lives in the home with her husband. Hours of operation are Monday through Friday 7:30am to 5:30pm.

On 3/4/2020 at 9:10 am: LPA observed that detergents, and cleaning compounds, and poisons were inaccessible to children in the kitchen under the sink, under the bathroom sinks, and in the back yard. All cleaners and poisons are kept in the garage inaccessible to the children.

Licensee does not have a current CPR/First Aid card and it expired on 9/26/2019. However; it is noted that the Licensee states that she has a current CPR /First Aid card but unable to locate it.

LPA toured the indoor and outdoor areas of the home during today's visit. LPA observed Parents’ Rights Poster PUB393, Personal Rights, and Emergency Disaster Plan posted in the home. The home has a swimming pool that meets regulations. The Licensee has a working telephone in the home. LPA observed sufficient materials and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. Off limit areas inside the home: Garage. Off limit areas outside the home: swimming pool area, and right side yard. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed operational smoke and carbon monoxide detectors. Licensee stated that there are no firearms or other dangerous weapons in the home. Licensee keeps a current Childrens Roster and Fire Drill Log. Most recent entry on the fire drill log was 11/11/2019. Licensee provided copies to the LPA.
REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 03/4//2020):
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
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 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: KAENI, SIMIN
FACILITY NUMBER: 434408192
VISIT DATE: 03/04/2020
NARRATIVE
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LPA reviewed the files of 4 children and 3 staff. All required documentation was in the files.

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 reviewed the Licensee’s documentation. LPA observed that the Licensee and staff have completed the required Mandated Reporter training (AB1207). LPA observed the required immunizations against Pertussis, Measles and an Influenza on file for the Licensee. Supervision of children was discussed with the Licensee and does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.

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. LPA discussed and provided Lead Safety Information (AB2370) with the Licensee.
REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 03/04/2020):
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
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: KAENI, SIMIN
FACILITY NUMBER: 434408192
VISIT DATE: 03/04/2020
NARRATIVE
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A deficiency is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D, An exit interview was conducted, and Plan of Corrections were reviewed and developed with the licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Simin Kaeni, 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 KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
LIC809 (FAS) - (06/04)
Page: 3 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: KAENI, SIMIN
FACILITY NUMBER: 434408192
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2020
Section Cited

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102416 (c) CPR / First Aid: Personnel Requirements. The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation and pediatric first aid.
This requirement is not met as evidenced by:
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Per LPA's review of files, Licensee does not have current Pediatric CPR/First Aid certification on file. This poses a potential risk to the health and safety of children.
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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) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4