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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406962
Report Date: 05/03/2022
Date Signed: 05/03/2022 01:16:11 PM

Document Has Been Signed on 05/03/2022 01:16 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:HABIBI, FARIDEHFACILITY NUMBER:
073406962
ADMINISTRATOR:HABIBI, FARIDEHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 231-5924
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 7DATE:
05/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Farideh HabibiTIME COMPLETED:
01:20 PM
NARRATIVE
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On May 3, 2022 at 11:45AM, Licensing Program Analyst (LPA) Catherine Fernandes arrived unannounced on a case management inspection regarding an incident that occurred on 3/30/22. LPA met with Licensee Farideh Habibi, there were three infants, four preschoolers and two additional staff present for the inspection. A roster was obtained.

There was an incident that occurred on 3/30/22, where an infant touched a hot pot that was placed on a cart within reach and burned his/her hand and wrist. The licensee stated she observed the infant touch the pot however the infant never cried and she assumed nothing happened. After lunch the licensee washed the infants hands and that's when she realized the infant's hand and a part of his wrist as injured. The licensee then administered first aid and contacted the family.
As of today the infant was at the day care.

Due to the incident a type A citation is being issued.

The attached type A violations is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgment form of proof of receiving this report (LIC9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.

See 809D

Exit interview conducted
Report and Appeal Rights provided
Notice of site visit must be posted for 30 days .
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
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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Document Has Been Signed on 05/03/2022 01:16 PM - It Cannot Be Edited


Created By: Catherine Fernandes On 05/03/2022 at 12:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HABIBI, FARIDEH
FACILITY NUMBER: 073406962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2022
Section Cited
CCR
102423(a)(2)

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Personal Rights- Each child receiving services from a family child care home...rights include, but are not limited to, the following: (2)To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement has not been met as evidenced by:
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Licensee is to submit a written plan to ensure the transition from play time to lunch time is structured and safe for all children in care.

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Based on conformation from the licensee an infant burned his/her hand and wrist, which is an immediate risk to children in care.
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Catherine Fernandes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022


LIC809 (FAS) - (06/04)
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