434416213-7-9-2020-07-CC-DMAC-BRCM4L-20200709091651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416213
Report Date: 07/06/2020
Date Signed: 07/09/2020 09:16:57 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:	NIKFARJAM, MOJGAN		FACILITY NUMBER:	434416213
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 3	DATE:	07/06/2020
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Mojgan Nikfarjam		TIME COMPLETED:	11:30 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) Dung Mac conducted an announced case-management tele-inspection via video conference call (FaceTime) with Mojgan Nikfarjam, Licensee, as a result of Covid-19 related restrictions. Licensee submitted the application to the Department on April 06, 2020. A fire safety inspection request approval was received from the Sunnyvale Fire Department on June 30, 2020. Days and hours of daycare will be Monday to Sunday from 8:00AM to 7:00AM. LPA observed Licensee's spouse (Ali Nikfarjam), Licensee's daughters (Newsha Nikfarjam and Niloufar Nikfarjam), three children in care, of whom three were one infant and two preschoolers in the home during today's tele-inspection. The adults that reside in the home: Licensee, Licensee's spouse (Ali Nikfarjam), and Licensee's daughters (Newsha Nikfarjam and Niloufar Nikfarjam). All individuals subject to a criminal record review (Licensing & adults residing home) have obtained a criminal record and child abuse index clearances prior to today's tele-inspection. Licensee agreed to give LPA a tour of the home (indoor/outdoor) via FaceTime during today's tele-inspection. Licensee's First Aid and CPR certifications are current and expire on July 13, 2021. Licensee's Mandated Reporter Training expires 1/26/2021. Licensee's copies of immunization records are on file. Licensee opted out flu vaccine. Licensee rents the home and copies of the signed Owner/Landlord Notification (LIC 9151) and Owner/Landlord Consent (LIC 9149) forms, and the Lease Agreement are on file. Licensee does not carry liability insurance and understands that if liability insurance is not carried, she will have the parents complete the Affidavit Regarding Liability Insurance (LIC 9182). Licensee states that she does not transport children. Report continued on Page 2

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2020

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: NIKFARJAM, MOJGAN	FACILITY NUMBER: 434416213
	VISIT DATE: 07/06/2020

NARRATIVE

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Report continued from Page 1

LPA observed the home is clean and orderly, with heating and ventilation for safety and comfort. LPA observed there are safe and age appropriate toys, play equipment, and materials for the children in the home. LPA did not observe fireplace and any wall heaters inside the facility. LPA observed the home has working smoke/carbon monoxide detectors (tested by the Licensee during today's tele-inspection). Licensee has a first aid kit in the home, which also has a thermometer and sufficient emergency supplies.

LPA informed Licensee that smoking is prohibited in the home during daycare hours. Licensee understands and states that nobody smokes in the home. Licensee states that she does not have any baby walkers and incline sleepers in the home and understands that baby walkers and incline sleepers are not allowed in the home. Licensee states that she does not baby bouncers, Johnny jumper, saucer chairs, and trampoline on the premises. LPA observed that electrical outlets are inaccessible to children. Licensee states that she does not have any firearms or pets in the home.

There is a working telephone in the home. Licensee states that the off limit areas inside the home are: bedroom #1, master bedroom, master bathroom, and detached garage. Licensee states that bedroom #2 is used for infant to take nap. Licensee designates a room in the home where a child(ren) can be isolated if exhibiting signs of illness. LPA observed the facility has a fully charged fire extinguisher (2A10BC) in the home. LPA observed medications are inaccessible to the children. Licensee states that there are no poisons inside the home.

The off limit area outside is left side of the house. LPA observed there is a secured fence to prevent children from having access to off-limit area. LPA observed the right side of the house has a locked gate.

LPA toured the kitchen and observed sharp utensils and cleaning compounds are inaccessible to children. Licensee understands that any food/drink which is brought by parent(s) of day care child(ren) must be properly labeled with the child(ren) name and properly stored or refrigerated.

Report continued on Page 3

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2020

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: NIKFARJAM, MOJGAN	FACILITY NUMBER: 434416213
	VISIT DATE: 07/06/2020

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Report continued from Page 2

LPA toured a bathroom and observed that the bathroom toilet and faucet are clean, safe, and operable. LPA observed that the bathtub and shower are free of any hazards. LPA observed a locked cabinet in the bathroom. LPA observed that all shampoos, soap, medication, mouthwash, perfumes, razors, cleaning products, air fresheners, and nail polish/remover are inaccessible to children.

LPA toured the backyard area. LPA observed backyard is safe and secure for children. LPA observed that the backyard area is adequately fenced and there are no bodies of water. LPA observed there is cushioning around play structures. LPA reminded Licensee that the children must be supervised at all times while outdoors.

Incidental Medical Services (IMS) policy was discussed with Licensee during today's tele-inspection. Licensee stated she does not have any children in care who requires administration of medication. Licensee states that the facility is not providing Incidental Medical Services at this time. The following US Department of Justice resource was provided: http://www.ada.gov/childqanda.htm.

A Family Child Care Home packet with updated Licensing forms, COVID-19 resources (Self-Assessment Guide, CHHS Postings, PPE Guidance), COVID-19 Updated Guidance, “Lead Poisoning Facts Information Flyer”, and "Safe Sleep" Information were mailed to the Licensee prior to today's tele-inspection and Licensee acknowledged receipt of the packet.

Licensee was informed that due to the current Covid-19 and "Shelter In Place" Order, the Facility Evaluation Report will be emailed to Licensee
(email: luckystarfamilycare@gmail.com) with "Read Receipt" notification. Licensee understands that her reply to the email will serve as acknowledgement that the report was received.

LPA conducted an exit interview and advised Licensee that a large Family Child Care Home license will be approved upon receiving of Acknowledgement of "receipt" of today's report and the approval of manager.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2020

LIC809 (FAS) - (06/04)

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