434411132-3-10-2020-07-CC-AALZ-BMKNTM-20200310104457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411132
Report Date: 03/10/2020
Date Signed: 03/10/2020 10:45:06 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:	GHOLALMI, FARIDEH & RASTBAF, FARIBA		FACILITY NUMBER:	434411132
ADMINISTRATOR:	FARIDEH& FARIBA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 978-1135
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	14	CENSUS: 9	DATE:	03/10/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Gholami, Farideh		TIME COMPLETED:	11:01 AM

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) Almaraz, Araceli conducted 1 year required inspection. LPA Almaraz met with Licensee, Gholami. Farideh and explained the nature of today's inspection. Present during the inspection was the licensee and assistants Gaska, Jossie and Kakaeinejad, Maryam. There were nine children present, including three infants, six preschoolers. The hours of operation of the day-care are 7:30AM to 6:00PM, Monday through Friday. There are two adults residing in the home; Licensee and assistant Kakaeinejad. Physical Plant: LPA Almaraz inspected the indoor and outdoor areas of the home today. Off limit areas in the home are as follows; Living room, kitchen, staff bathroom. Off limit areas outside the home are as follows: Garden area, fenced. The front yard is safety compliant and backyard is fully fenced. Licensee states that there are no weapons in the home. LPA Almaraz did not observe any bodies of water inside or outside the home. Medication, cleaning products and similar items are stored inaccessible to children. Poisons must be locked. Licensee has no pets. Facility Records: Licensee Gholami and assistants have CPR and First Aid, which has an expiration date of 09/30/2019. All provided proof of enrollment for 03/19/2020. Licensee will send proof of completion on 03/20/2020. LPA observed that the Licensee and assistants have record of MMR & Tdap vaccinations as well as the opt out for the flu vaccine. Licensee and assistant Gaska have completed Mandated Reporter Training on 01/07/2020, licensee understands training is to be completed every two years. Assistant Kakaeinejad awaiting Mandated Abuse Reporter Training to be available in primary vernacular. 1/3

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2020

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: GHOLALMI, FARIDEH & RASTBAF, FARIBA	FACILITY NUMBER: 434411132
	VISIT DATE: 03/10/2020

NARRATIVE

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LPA Almaraz reviewed eight children's files and observed current and updated immunization records and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. LPA observed a current roster, a current fire disaster/earthquake drills last log 01/17/2020. Licensee has day care insurance.

LPA Almaraz observed a working smoke/carbon monoxide detector, 3A40BC fire extinguisher. LPA did not observe any heaters in the home. LPA observed a barricaded fireplace.

Supervision of the children was discussed; the Licensee understands a cleared adult must be present in the home during day care hours. Licensees understand that the children must be supervised at all times. The Licensee understands the capacity options and ratio requirements. Licensee understands not to leave children in the car unattended. The Licensee states that there is transporting of children currently.

Incidental Medical Services (IMS) policy was discussed. 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. 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

A review of staff records on 03/09/2020 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 2/3

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2020

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: GHOLALMI, FARIDEH & RASTBAF, FARIBA	FACILITY NUMBER: 434411132
	VISIT DATE: 03/10/2020

NARRATIVE

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

There are no deficiencies during today’s inspection.

For an updated list on recall products please visit www.safekids.org

LPA Almaraz conducted an exit interview with Licensee Gholami and advised the licensee of the pending Department regulation update re: safe sleep for infant children. LPA referred the Licensee to the Department website: www.ccld.ca.gov for additional information. LPA discussed the requirements of AB633 to Licensee.

NOTICE OF SITE VISIT WAS ISSUED, MUST BE POSTED FOR 30 CONSECUTIVE DAYS. 3/3

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2020

LIC809 (FAS) - (06/04)

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