444415860-6-8-2022-07-CC-CNEN-CF7SBM-20220608134411

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444415860
Report Date: 06/08/2022
Date Signed: 06/08/2022 01:44:34 PM

Document Has Been Signed on 06/08/2022 01:44 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	MAZLOOM, SEDIQUE		FACILITY NUMBER:	444415860
ADMINISTRATOR:	MAZLOOM, SEDIQUE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 656-1590
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	14	CENSUS: 12	DATE:	06/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Sedique Mazloom		TIME COMPLETED:	02:00 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	Licensing Program Analyst (LPA), Cortney Nelson, met with Licensee, Sedique Mazloom, for an unannounced Required- 1 Year Inspection. LPA was granted access to the home by Assistants, Samantha Congrove & Crystal Rozinsky, and toured both indoors and outdoors during the inspection. Licensee was not present upon arrival, Assistants state that she was dropping off her daughter to another program. Licensee arrived to the facility around 11:00AM. Upon arrival, there were 12 children (7 preschool age/ 3 infants/ 2 school-age) and 2 staff present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday, 8:00AM-5:00PM. Licensee states that adults, over the age of 18, residing in the home are: herself and her spouse (Ali Hajdaei). Licensee states that her husband resides in the home only periodically. All adults residing in the home have Criminal Background Check Clearance and signed Criminal Record Statements (LIC508). Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated. LPA reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The last fire/disaster drill was conducted on 6/6/2021, which is not compliant with the six-month requirement for homes. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke detector and carbon monoxide detector. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. The Licensee states that there are no weapons or firearms in the home.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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: MAZLOOM, SEDIQUE	FACILITY NUMBER: 444415860
	VISIT DATE: 06/08/2022

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. 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. The following information regarding ADA was provided: US Department of Justice 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: http://www.ada.gov/childqanda.htm

Indoor areas of the home were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Off-limits areas inside the home include: entire upstairs and attached garage. Licensee states that children primarily stay outside during operating hours and inside the home is utilized for naps. There are no open-faced heaters in the home. Licensee has an electric fireplace unit in the home that is unplugged and will not be used during day care hours. LPA advised Licensee on process to submit request for waiver for fireplace. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The day care home provides snacks to the children, however all meals are brought to the facility by the children. Licensee states that children's lunches are stored in refrigerator if they need refrigeration. Two containers of infant formula were observed to be open without proper labeling of name or date. The bathroom in the home is clean, sanitary, and operable. LPA advised that additional bathroom located in the home should not have supplies that should be inaccessible to children, even if only used in emergency. The Licensee has a working telephone (cellphone) in the facility. Stairs are barricaded appropriately to keep day care children safe.

The backyard area of the home was inspected and observed to have sufficient play-equipment and supplies for the children. Off-limit areas outside of home include: both side yard areas beyond the fenced play area. There is a hot tub located outside of the fenced area for children and is properly secured with a weight bearing cover that is latched down. Chickens and rabbits are located in the backyard in fenced enclosures that are safe for children to use with staff supervision. Licensee has a trampoline and LPA advised that prior to use the trampoline is placed on level ground, cleaned off, and supervised at all times while children are using it.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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: MAZLOOM, SEDIQUE	FACILITY NUMBER: 444415860
	VISIT DATE: 06/08/2022

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-and-resources/safe-sleep as an additional resource.

12 children’s files were reviewed during todays inspection and most required documents were present, including Affidavit Regarding Liability Insurance (LIC282). LPA advised Licensee on Safe Sleep requirements for infants in care including documented nap checks and Individual Infant Sleep Plan (LIC9227) for infants 12 months and under.

Assistant, Licensee, and Spouse files were reviewed and most required documents were present. There is at least one staff member present with current CPR/First-Aid that expires 6/26/2023. The Licensee's Mandated Reporter Training expired on 2/5/2021 and LPA advised that Licensee and all staff must renew the training every 2 years.

Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Sedique Mazloom.

As a result of todays inspection, deficiencies were cited, see 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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: MAZLOOM, SEDIQUE	FACILITY NUMBER: 444415860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as last fire drill was conducted 6/6/2021, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/15/2022
	Plan of Correction
1 2 3 4	Licensee will conduct fire drill by 6/15/2022 and submit updated log to Licensing.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of 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
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above for 3 out of 3 staff present, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/15/2022
	Plan of Correction
1 2 3 4	Licensee will submit current Mandated Reporter certificate for herself and assistants (Samantha & Crystal) by 6/15/2022. Website to access training: www.mandatedreporterca.com (AB1207- Child Care Providers)

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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: MAZLOOM, SEDIQUE	FACILITY NUMBER: 444415860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above for one child in attendance, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2022
	Plan of Correction
1 2 3 4	Licensee will submit emergency information card for 1 child in care by 6/10/2022. Children's file must be maintained for all children in care.

Type B

Section Cited

CCR

102418(a)

Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above for 4 out of 12 children's files, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2022
	Plan of Correction
1 2 3 4	Licensee will submit proof of immunization record for 4 children by 6/10/2022 and maintain current immunization documentation in childrens files.

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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: MAZLOOM, SEDIQUE	FACILITY NUMBER: 444415860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) 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 and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above for 2 out of 12 children in care, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2022
	Plan of Correction
1 2 3 4	Licensee will submit signed Notification of Parents Rights by 6/10/2022 and maintain document in children's file.

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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: MAZLOOM, SEDIQUE	FACILITY NUMBER: 444415860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102369(b)(9)

102369 Application for Initial License (b) The applicant shall provide all of the following information at the time of submission of the application... (9) Evidence of a curent tuberculosis clearance, not more than one year prior to or seven days after initial presnce in the home, for any adult in the home during the time that children are under care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above for 1 staff member, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2022
	Plan of Correction
1 2 3 4	Licensee will submit proof of negative TB test for her assistant, Crystal, by 6/22/2022. (TB test results must be within 1 year of hire if submitting previous test.)

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC809 (FAS) - (06/04)

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