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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411132
Report Date: 02/13/2025
Date Signed: 02/13/2025 04:41:09 PM

Document Has Been Signed on 02/13/2025 04:41 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GHOLAMI, FARIDEHFACILITY NUMBER:
434411132
ADMINISTRATOR/
DIRECTOR:		GHOLAMI, FARIDEHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 978-1135
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 14TOTAL ENROLLED CHILDREN: 2CENSUS: 2DATE:
02/13/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Farideh Gholami TIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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At 2:10PM, Licensing Program Analysts (LPAs) Angela Luz and Andy Yang met with Licensee Farideh Gholami to conduct an unannounced 3-YEAR REQUIRED inspection. Present for this inspection were licensee, (2) children (1 infant & 1 preschool age), and partially fingerprint cleared resident adult. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday-Friday 7AM-6PM.

Facility:
The OFF LIMIT AREAS are Master bedroom and bathroom, living room, kitchen, dining room, and pantry/laundry room. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. The home is neat and clean with heating and ventilation for safety and comfort. The outdoor play area is free from defects or dangerous conditions and is fully fenced. There is a large play structure that is anchored to the ground. The play structure has swings and a slide with gravel underneath. There are no bodies of water. All hazardous materials and toxins are kept out of the reach of children. Licensee states that there are no firearms in the home. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone.

Care and Supervision:
There are ample age-appropriate toys that appear to be safe and in good condition. All cribs or play yards meet the safety standards. The cribs or play yards do not hinder entrance or exit to and from the space where infants are sleeping. The mattresses in the crib or play yards are firm and covered with a fitted sheet that is appropriate, fits tightly, and overlaps the underside of the mattresses. Each infant’s bedding is used for them only and cleaned weekly or before use by another infant. LPAs observed blankets and a book inside the play yard, and blankets hanging on the side of the play yard while an infant was sleeping.

***Page 1 of 3***
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Angela Luz
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 5
Document Has Been Signed on 02/13/2025 04:41 PM - It Cannot Be Edited


Created By: Angela Luz On 02/13/2025 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GHOLAMI, FARIDEH
FACILITY NUMBER: 434411132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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POC was corrected at time of inspection. Licensee will ensure there cribs or play yards are free from all loose articles and objects. At time of inspection, licensee has removed the blankets from the crib.
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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By plan of corrections due date 2/28/25, Licensee will document 15 minute sleep checks that include date, name of child, time of check, and notate any signs of distress. Licensee will submit proof of the documentation.
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:Belinda Devall
LICENSING EVALUATOR NAME:Angela Luz
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GHOLAMI, FARIDEH
FACILITY NUMBER: 434411132
VISIT DATE: 02/13/2025
NARRATIVE
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Licensee uses redirection as forms of discipline. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature.

Records: The Licensee CPR and First Aid certificate is current and expires 4/25/26. Licensee Mandated Reporter Training for Child Care Providers expired 4/11/24. Licensee was reminded of Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file. The Licensee conducts and documents fire and disaster drills every six months, last drill was on 12/7/24. Entrance checklist for Family child care home was provided and licensee was reminded of documents to be posted in a prominent, publicly accessible area of the facility.

LPA Luz reviewed 2 children files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization records. Documentation of infant sleep checks every 15 minutes that notate any signs of distress was missing from infant file.

LPA, Luz reviewed two (2) staff (S1 and S2) files for the following records: Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunization records, and required training.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries to inspectionprocess@dss.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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
***Page 2 of 3***
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Angela Luz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GHOLAMI, FARIDEH
FACILITY NUMBER: 434411132
VISIT DATE: 02/13/2025
NARRATIVE
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, Farideh Gholami, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Megan's Law was checked on 2/11/25.

During today's inspection, (4) Type B deficiencies are issued on attached page 809-D. Appeal rights were provided.
  • Partially fingerprint adult resident
  • Loose articles in play yard
  • 15 minute sleep check documentation missing
  • Expired mandated reporter certification

A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the Licensee, Farideh Gholami.

***Page 3 of 3, End of Report***
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Angela Luz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/13/2025 04:41 PM - It Cannot Be Edited


Created By: Angela Luz On 02/13/2025 at 03:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GHOLAMI, FARIDEH
FACILITY NUMBER: 434411132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.871
All individuals subject to a criminal record review, persuant to Health and Safety Code Section 196.871 shall complete a Child Abuse Central Index check, prior to employment, residence or intial presence in the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on background inspection, an adult (grandson) living in the home did not receive background clearance for Child Abuse Central Index] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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By POC due date of 2/14/2025, Licensee will show proof of receipt for grandson initiating the live scan finger print process for background clearance.
Type B
Section Cited
HSC
15968662(b)(1)
On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) 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 is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee does not have current mandated reporter training certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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POC due date of 2/28/2025, Licensee will provide copy of Mandated reporter training certificate.
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:Belinda Devall
LICENSING EVALUATOR NAME:Angela Luz
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
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