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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414697
Report Date: 09/26/2019
Date Signed: 09/26/2019 04:12:48 PM

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:HOSSEINI, MITRAFACILITY NUMBER:
434414697
ADMINISTRATOR:HOSSEINI, MITRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 666-9965
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:14CENSUS: 6DATE:
09/26/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:06 PM
MET WITH:Mitra HosseiniTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Marilou Monico and Pete Hernandez, made an unannounced annual random inspection. LPAs met with Licensee, Mitra Hosseini, and explained the nature of today's inspection. Also present in the home were licensee's husband, adult helper, and 6 daycare children including 4 infants and 2 preschool age. Days and hours of operation are Monday to Friday from 8:00 AM to 6:00 PM. There are five adults residing in the same address: licensee, her husband, her son, and two adult renters in the rental unit located in the back area of the home.

LPAs toured the home both indoor and outdoor. LPAs observed sufficient materials, toys, and play equipment for the day care children. LPAs observed the following: fully charged 3A40BC fire extinguisher, working smoke detector, functioning carbon monoxide detector, barricaded fireplace, and no bodies of water. Off limit areas in the home: 2 bedrooms, 1 bathroom, kitchen, laundry room, and family room. Off limit areas outside the home: detached rental unit, detached garage, vacant space next to the garage, and left side section of the home. Medications, cleaning compounds, sharp objects, and other similar items are stored out of reach of children. Per licensee, there are no weapons in the home. Six children's files were reviewed. Child #1 is missing immunization records and completed and signed Notification of Parents' Rights Receipt in the file. Licensee maintains a current children's roster and fire drill log. LPAs obtained copies of children's roster. Licensee has current CPR/First Aid certifications with an expiration date of April, 2021. The home has a working telephone which is (408) 666-9965.

LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years. AB 633 was discussed with Licensee. Licensing forms, Title 22 regulations, can be obtained through the internet at ww.ccld.ca.gov. Mandated Reporter Training can be accessed at www.mandatedreporterca.com. Licensee and her helper have completed the Mandated Reporter Training.

(REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 09/26/19:
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2019
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 3
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: HOSSEINI, MITRA
FACILITY NUMBER: 434414697
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2019
Section Cited

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IMMUNIZATIONS - The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by: Child #1 is missing proof of immunizations in the file. This poses a potential risk to the health and safety to children in care.
Type B
10/10/2019
Section Cited

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Admission Procedures and Parental and Authorized Representative's Rights - The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file
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This requirement is not met as evidenced by: Child #1 is missing Notification of Parents' Rights Receipt in the file. This poses a potential risk to the health and safety to children in care.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: HOSSEINI, MITRA
FACILITY NUMBER: 434414697
VISIT DATE: 09/26/2019
NARRATIVE
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(CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 09/26/19):

A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemption.

As a result of this inspection, deficiencies were cited on the following page:



NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3