434416201-9-16-2021-07-CC-AMOS-C6WRX9-20210916132423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416201
Report Date: 09/15/2021
Date Signed: 09/16/2021 01:24:45 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:	AFRAKHTEH, AZIZEH		FACILITY NUMBER:	434416201
ADMINISTRATOR:	AZIZEH AFRAKHTEH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 966-0113
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	14	CENSUS: 6	DATE:	09/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Azizeh Afrakhteh		TIME COMPLETED:	03:25 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	(#1)Licensing Program Analyst (LPA) Anna Morales conducted an ANNUAL REQUIRED visit. LPA was greeted Licensee Azizeh Afrakhteh and six children. One child is under two years old and the other children are between the ages of two years to four years old. LPA observed a current copy of Current Children Roster during visit. Days and hours of operation are Monday - Friday from 8:30 AM -5:15PM. Adults over the age of 18 residing in the home are the Licensee, spouse and two sons. All adults residing have Criminal Background Check Clearances, signed Criminal Record Statements LIC508 on file with Licensing Office. LPA toured the indoor and outdoor areas of the home during today's inspection: INDOOR SPACE: The day care areas for use include: the family room (main activity area, one bedroom, one restroom, and the backyard. All other areas / bedrooms in the home are off-limits which includes the kitchen, the garage, two bedrooms, one restroom, and a portion of backyard. Children/parents enter the day care through the side gate. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Furniture and equipment, such as, mats, chairs, and tables were age appropriate and in good condition. There were no baby walkers or bouncers observed on the premise during today’s inspection. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters. LPA observed a fully charged 2A10BC fire extinguisher, functional smoke and carbon monoxide detectors, and first aid supplies in the home. There are fireplaces in the home, located in the on-limit family room (main activity room) and off-limit living room which are both secured with front gate coverings. The fireplace in the on-limit family room is secured with a perimeter gate. Page 1

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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: AFRAKHTEH, AZIZEH	FACILITY NUMBER: 434416201
	VISIT DATE: 09/15/2021

NARRATIVE

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LPA reviewed a random selection of Emergency Information Cards (LIC700) and they were complete and updated. LPA observed sleep log for the child who is under two years old.

LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes in contact with or provide 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.

Incidental Medical Services (IMS) policy was discussed. Licensee stated that they do not take care of children who are ill. 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. Licensees have an area where sick children can be isolated from the others until parent pick-up.

Licensee does have current Mandated Reporter Certificate. The last Mandated Reporter Certificate expires 5/23/2023. 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 atwww.mandatedreporterca.com.

Licensee has current CPR and Pediatric First Aid card. It expires in 8/2023

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

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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: AFRAKHTEH, AZIZEH	FACILITY NUMBER: 434416201
	VISIT DATE: 09/15/2021

NARRATIVE

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LPA discussed the requirements of AB 633 with the Director and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). 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. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

NO CITATIONS WERE CITED AT TODAY'S VISIT.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC809 (FAS) - (06/04)

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