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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423671
Report Date: 11/03/2021
Date Signed: 11/03/2021 12:42:39 PM

Document Has Been Signed on 11/03/2021 12:42 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SHARIFI, SHADIFACILITY NUMBER:
013423671
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
11/03/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shadi SharifiTIME COMPLETED:
12:50 PM
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Licensing Program Analyst Lisa Dyer conducted an announced pre-licensing inspection. Present were the applicant and her fingerprint cleared spouse. The home was toured and consists of 2 bedrooms, 2 bathrooms, living room, dining room, kitchen, and the basement which has a day care area and a laundry/storage area. The day care area consists of a large room, kitchenette, bathroom and a adjacent room. Children will enter the day care area by walking down the side of the home and enter through the rear. Off limits areas are the other section of the basement and the rest of the home, as well as the yard. These areas will be inaccessible by closed and/or locked doors; gates and visual supervision.

At 9:50 a.m., the following was observed: Stairs are blocked with a closed door. Isolation area for sick children will be in the adjacent room. There are no toxins accessible today. There is a box heater in the day care area. There is a 3-A:40-B:C fully charged fire extinguisher, a working smoke detector (tested), carbon monoxide detector and a first aid kit. There are minimal toys. Applicant has one bed and will obtain cots/mats/pack-n-plays for additional children. Per applicant, there are no firearms on the premises. There is a fireplace in the living room. She has a cell phone and a home phone. Hot tub in the back yard is fenced and locked. Backyard is currently not safe for child play and will not be licensed. Children will play at the park or taken for walks. No pets. There are 2 fingerprint cleared adults that live in the home.

Training: Applicant has completed Preventative Health Training on 4/6/21. CPR/First Aid Training expires 5/15/23. Mandated Reporter Training certificate expires 10/18/23. The applicant's husband is the owner of the property, and verification was viewed.

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. (continued)
SUPERVISORS NAME: Phyllis Dyer
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SHARIFI, SHADI
FACILITY NUMBER: 013423671
VISIT DATE: 11/03/2021
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 The following information regarding ADA was provided: US Department of Justice (USDOJ) 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.

Licensing forms were provided and reviewed to maintain facility and children's files; and to post in public area. Applicant was instructed to conduct and document periodic fire and disaster drills. Discipline methods were discussed. Applicant was instructed that spanking is not allowed. Proposed hours of operation: 8:00 am - 6:00 pm. The handout, "A Child Care Provider's Guide to Safe Sleep" was provided and discussed, along with Individual Infant Sleeping Plan requirements. Applicant was informed that baby bouncers, johnny jumpers, and saucer chairs were not allowed in the home; and that all persons 18 years of age or older who frequently visit, work or reside in the home shall be fingerprint cleared prior to being in the presence of day care children. Also discussed: children in parked vehicles; substitutes; training videos; changes to the facility; fingerprinting/association; advertisements; large family child care homes, smoking and Zero Tolerance Regulations. Applicant was reminded that Mandated Child Abuse Training, as well as First Aid/CPR training is required to be completed every 2 years.

Applicant was given Title 22 regulations, and reminded that licensing updates and forms can be located on our website: www.ccld.ca.gov. For CCL Updates, go to www.ccld.ca.gov. Click the "Receive Important Updates" box. Enter your e-mail address for the Child Care Advocate Program.

Websites: Alameda County Public Health Department Website: www.acphd.org
Guardian Background Check: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

The applicant was requested to complete the following item(s) prior to the issuance of a license:
1. Fence box heater so it is inaccessible to children. 2. Remove branches in front yard. 3. Remove standing water in tub. 4. Block fireplace. 5. Move items in back yard.

Applicant states that items will be completed by November 25, 2021. (Additional information may be requested.) Exit interview conducted. Applicant was given appeal rights.
SUPERVISORS NAME: Phyllis Dyer
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
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