434409424-6-22-2023-07-CC-FRAA-CT2RB6-20230622125213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409424
Report Date: 06/20/2023
Date Signed: 06/22/2023 12:52:22 PM

Document Has Been Signed on 06/22/2023 12:52 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	PARVIN, SHAHANEWAS		FACILITY NUMBER:	434409424
ADMINISTRATOR:	PARVIN, SHAHANEWAS		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 239-0231
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY:	14	CENSUS: 12	DATE:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Parvin Shahanewas		TIME COMPLETED:	01:30 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 06/20/2023 at 9:22am, Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced 1- year annual inspection. LPA was granted access to the home by Licensee, Parvin Shahanewas, and explained the nature of today’s inspection. Present in the home were Licensee and Licensee's spouse/assistant and 12 children including 3 infants and 9 preschool age. Licensee's assistant(S3) arrived at 9:28 am and second assistant (S2) arrived at 10:05 am. Days and hours of operation are Monday to Friday, 8:00 am to 6:00 pm. LPA observed all required posted materials, in the family room of the home. This facility has one waiver that allows a waterfall in the front yard which was filled with plants. Licensee was in compliance with the conditions of the waiver. The adults that reside in the home are Licensee and Spouse. No minor children reside in the home. LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home (408-204-4329). LPA observed sufficient materials, toys, and play equipment for the day care children. Furniture, such as tables, chairs, feeding chairs and shelves, are in good condition. The floors were free of tripping hazards. The home has central heating/cooling and ventilation for comfort of children. The home is single story. Off limit areas inside the home: master bedroom, master bathroom, three bedrooms, attached garage and barricaded fireplace in the family room. There are no stairs or wall heater units inside the home. Off limit areas outside the home: right side section including the locked shed and gated left side section. Backyard is fenced and play structures and outdoor toys were observed to be maintained in safe condition and free of hazards. There are no bodies of water observed. LPA observed that the bathroom used by children was in operating condition. Toilets and faucet are clean and operable. The shower area is free on any hazards. Continued on Page 2

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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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Document Has Been Signed on 06/22/2023 12:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PARVIN, SHAHANEWAS	FACILITY NUMBER: 434409424
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) 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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above for 3 out of 4 staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/04/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of immunizations for herself and two assistant staff by Plan of Correction date of 07/04/2023.

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: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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

FACILITY NAME: PARVIN, SHAHANEWAS	FACILITY NUMBER: 434409424
	VISIT DATE: 06/20/2023

NARRATIVE

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LPA observed a 3A40BC fire extinguisher in the hallway to the bedrooms that was not recharged. Licensee's spouse was able to purchase a new fire extinguisher while LPA was present and provided the receipt during today's inspection. Licensee has working smoke/carbon monoxide detectors and fire pull station. The Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, medications, sharp objects and other similar items are stored inaccessible to children. Licensee understands that smoking is prohibited in the home.

Drinking water is readily available for children in the home via individual water bottles/sippy cups. Licensee states that she provides AM snack, lunch and dinner to the children in care. Licensee is part of the Love Children Food Program.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Fire/disaster drill was conducted on 05/19/2023. LPA obtained copy of children's roster. Children file review was completed and found to be current and up to date. Eleven (11) children’s files were reviewed during today's inspection. Licensee does not have liability insurance for the day care and issues the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282). LPA reviewed three (3) infant children's files and did not observe nap check documentation. LPA discussed the safe sleep regulations with Licensee, including documentation that shall be maintained and conducting 15-minute checks on all sleeping infants. LPA discussed the 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 provided licensee with a copy of an Individual Infant Sleeping Plan (LIC 9227) and a sample 15- minute sleeping infant check form.

Staff file review was completed. LPA reviewed four (4) staff files. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee has current Pediatric CPR/First Aid certification with an expiration date of 01/06/2025. Licensee and two assistants (S3 and S4) could not provide proof of immunization for measles and pertussis, according with the SB792. Licensee's Mandated Reporter Training expires on 08/23/2024. Licensee understands the training is mandatory to all Licensees and adults in the home in contact will children and requires renewal every two years. Licensee states that she does not transport any day care children.

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SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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

FACILITY NAME: PARVIN, SHAHANEWAS	FACILITY NUMBER: 434409424
	VISIT DATE: 06/20/2023

NARRATIVE

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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. 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 Licensee, and she understands that she or a qualified adult must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a qualified assistant must be present. Licensee understands in absence of a helper her license capacity is reduced to 8 and ratio (age of the children) must be observed.

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. A $500 immediate civil penalty and $100 per day violation until corrected is assessed for serious violations such as absence of supervision, accessible bodies of water, accessible firearms, refused entry of licensing staff, presence of an excluded person, and violations that result in illness or injury.

Licensee is encouraged to visit the Department’s website at https://cdss.ca.gov/inforesources/child-care-licensing to access general updates, resources for providers, regulations, adoptions of new laws, pay annual fees etc.

Licensee states that a child will be isolated in the living room if necessary due to illness or communicable disease away from other children till parent pick-up. Licensee states that she does not administer any medications to the day care children at this time. Incidental Medical Services (IMS) policy was discussed. LPA provided Licensee with PIN 22-02. 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.

Continued on page 4

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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

FACILITY NAME: PARVIN, SHAHANEWAS	FACILITY NUMBER: 434409424
	VISIT DATE: 06/20/2023

NARRATIVE

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The following information regarding Americans with Disabilities Act (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.

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@dess.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/process.

One Type B deficiency was cited as a result of today's inspection. Appeal rights were printed and given to Licensee. Exit interview conducted and report was reviewed with the Licensee, Parvin Shahanewas.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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