434416213-10-7-2021-07-CC-ASHA-C7KVWW-20211007164838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416213
Report Date: 10/07/2021
Date Signed: 10/07/2021 04:48:49 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:	NIKFARJAM, MOJGAN		FACILITY NUMBER:	434416213
ADMINISTRATOR:	MOJGAN NIKFARJAM		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 663-0082
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	14	CENSUS: 5	DATE:	10/07/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:42 PM
MET WITH:	Mojgan Nikfarjam		TIME COMPLETED:	05:00 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	LPAs Aman Sharma and Samantha Yip conducted an unannounced Annual/Required Inspection. LPAs met with Licensee, Mojgan Nikfarjam. LPAs observed five children playing in the accessible areas of the facility. Licensee stated that there are no children under twelve months old. LPAs reviewed a current copy of Children's roster. Days and hours of operation are Monday - Friday from 8:00 AM to 5:30 PM. Last Disaster Drill was conducted on August 12, 2021. LPAs toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Outdoor activity space is enclosed by fencing and is observed to have a few toys that have cracks in them, but was not sharp. LPAs observed all other play equipment is in good condition. LPA's observed resilient materials under the climbing structures. Drinking water was readily available to children indoor and outdoor. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters inside the home. LPAs observed that there is a lemon tree and rose bushes in the backyard, which has thorns. LPA reminded Licensee to ensure that she is checking for thorns that are at the children's level. Off-limit areas inside are sectioned off by a small gate. LPA observed a fully charged 2A40BC fire extinguisher and working smoke/carbon monoxide detectors,. The Licensee states that she does not have any weapons in the home. Licensee does have chicken in the backyard. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. LPA reminded Licensee that anything that states to keep out of reach of children, such as disinfectant wipes and diaper cream, should be inaccessible. LPAs also observed that there was blade for a food processor on the bottom cabinet. Licensee moved food processor to a higher shelf during today's inspection. (page 1)

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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: NIKFARJAM, MOJGAN	FACILITY NUMBER: 434416213
	VISIT DATE: 10/07/2021

NARRATIVE

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LPA reviewed all children's files. LPAs observed that C-1 and C-2 did not have the notification of parents' rights forms (LIC 995A). Licensee stated that she will have the parents fill it out and send a copy to Licensing. A copy of the facility roster was obtained during today's inspection.

Incidental Medical Services (IMS) policy was discussed. The Licensee stated that she does not take care of children who are in need of any Incidental Medical Services. 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. Licensee has an area where sick children can be isolated from the others.

Licensee does not transport children, but understands that children cannot be left alone and unattended in parked vehicles.
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The adults over 18 years old are Licensee, her spouse, and her two daughters. 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.

Licensee has current Mandated Reporter Certificate. The last Mandated Reporter Certificate expires for Licensee 01/08/2023. 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 does have current CPR and First Aid card. It expires on 06/22/2024
(page 2)

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 10/07/2021

NARRATIVE

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

LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov

LPA conducted an exit interview with Licensee Mojgan Nikfarjam prior to the conclusion of today's inspection.

One Type B citation and one technical violation was issued during today's inspection. Appeal Rights were provided to Licensee during today's inspection.

LPA discussed and left a copy of Pin 20-24-CCP, RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT. Discussed that all INFANTS UP TO 12 MONTHS OF AGE MUST HAVE AN INDIVIDUAL INFANT SLEEPING PLAN (LIC9227) OF FILE, WHICH WILL DOCUMENT THE INFANTS SLEEPING HABITS, USUAL SLEEPING ENVIRONMENT, AND THE INFANT ROLLING ABILITIES. LPAs reviewed documentation that children are checked every 15 minutes during today's inspection. LPA also reminded Licensee that the door needs to be open when children are napping.

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

(page 3)

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/15/2021 Section Cited	1 2 3 4 5 6 7	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 as proof that the parent or authorized representative has been notified of his or her rights... This requirement is not met as evident by:
	8 9 10 11 12 13 14	Based on record reviews, LPAs observed that C-1 and C-2 did not have the bottom portion of the LIC 995A. This poses a potential risk to the health and safety to the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Sandy Knight	TELEPHONE: (408) 334-2153
LICENSING EVALUATOR NAME: Aman Sharma	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

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