434408192-3-22-2022-07-CC-PHEZ-CCRRM8-20220322130819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434408192
Report Date: 03/22/2022
Date Signed: 03/22/2022 01:09:01 PM

Document Has Been Signed on 03/22/2022 01:09 PM - It Cannot Be Edited

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, SIMIN		FACILITY NUMBER:	434408192
ADMINISTRATOR:	KAENI, SIMIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 871-2635
CITY:	SARATOGA	STATE: CA	ZIP CODE:	95070
CAPACITY:	14	CENSUS: 6	DATE:	03/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Simin Kaeni		TIME COMPLETED:	01:20 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	On 3/22/2022 at 9:30am: 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 6 children present at the time of the inspection; one infant and 5 preschoolers. Also present was her helper Eva Cerron. The Licensee lives in the home with her husband. Hours of operation are Monday through Friday 8:00am to 4:30pm. LPA observed that detergents, and cleaning compounds, and poisons were inaccessible to children. All cleaners and poisons are kept in the garage laundry room inaccessible to the children. Licensee does have a current CPR/First Aid card and it expired 9/23/2023. However; Her Helper, whom works there everyday who has a current CPR/First Aid card that expires on 7/24/2023 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: A properly fenced swimming pool area, and far 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 11/12/2021. Licensee provided copies to the LPA. REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 03/22/2022):

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

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: KAENI, SIMIN	FACILITY NUMBER: 434408192
	VISIT DATE: 03/22/2022

NARRATIVE

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LPA reviewed the files of 6 children. 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 clearances or exemptions. 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 Helper have completed the required Mandated Reporter training (AB1207). LPA observed the required immunization's against Pertussis, Measles and an Influenza on file for the Licensee along with all pther required documentation to complete the file. 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 03/22/2022):

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

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: KAENI, SIMIN	FACILITY NUMBER: 434408192
	VISIT DATE: 03/22/2022

NARRATIVE

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Licensee and Helper have a current Mandated Reporter Certificates. 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.

LPA discussed the Individual Infant Sleeping Plan form 9227. Licensee already uses this form.

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

Type A language: Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809D has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with the licensee. A copy of this report was 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: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC809 (FAS) - (06/04)

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