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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409195
Report Date: 10/20/2021
Date Signed: 10/20/2021 11:56:57 AM

Document Has Been Signed on 10/20/2021 11:56 AM - 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:SARBAZ, AFSHINFACILITY NUMBER:
073409195
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
10/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Afshin SarbazTIME COMPLETED:
12:30 PM
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On 10/20/2021 at 10:00 AM Licensing Program Analyst(LPA), Arminder Singh conducted an announced Pre-Licensing Inspection and met with Applicant, Afhsin Sarbaz. Applicant resides in the home with his two teen aged children (14 and 15 years old). During the inspection the Applicant was the only person home.

Applicant has applied for a Small Family Child Care Home with capacity for 8 children. Days and hours of operation will be Monday through Friday from 8:00 AM - 6:00 PM. Applicant has current Pediatric cardiopulmonary resuscitation (CPR) and First Aid and has current mandated reporter training. Applicant currently owns this property. Applicant has a working telephone in the home (925-497-8986). Isolation of sick child was discussed and the front of the living room #2 area of the home will be designated for that. Applicant understands that 100% supervision is required at all times.

At 11:00 AM: LPA toured the indoor space of the home with the Applicant. The home is a one story home with an attached garage. The home consists of three bedrooms, two bathrooms, kitchen, two living rooms, dining room,garage, and backyard.

IN USE AREAS: Living room #1, living room#2, dining room, kitchen, and bathroom #1.

OFF LIMIT AREAS: All bedrooms, bathroom #2 which is located in the master bedroom, and garage.
CONTINUED ON NEXT PAGE
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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: SARBAZ, AFSHIN
FACILITY NUMBER: 073409195
VISIT DATE: 10/20/2021
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The home is sanitary, safe and orderly, with central heating and ventilation for safety and comfort. There is a Non-working fireplace in the home that is properly barricaded and made inaccessible to children. LPA observed: fully charged fire extinguisher, working smoke and carbon monoxide detector. Medicines, cleaning products, sharp objects are stored and are made inaccessible to children in cabinets and out of reach of children. LPA reminded Applicants that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes. Applicant states there are no firearms and ammunition stored in the home. Applicant states there is no pets in the home.

Outdoor Play area is fully fenced, has a patio area and has one half shed that are made inaccessible by a gate. The outdoor play area has artificial turf that makes it a padded surface.

Applicant understands that children's personal rights should not be violated and no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed. Fire drills must be practiced once every six months and documented.

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 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. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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: SARBAZ, AFSHIN
FACILITY NUMBER: 073409195
VISIT DATE: 10/20/2021
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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 (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

LPA discussed 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 Applicants. Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.


CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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: SARBAZ, AFSHIN
FACILITY NUMBER: 073409195
VISIT DATE: 10/20/2021
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CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov

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

childcareadvocatesprogram@dss.ca.gov


This home is recommended for licensing effective 10/20/2021. LPA reminded the applicant that compliance with all Title 22 regulations and applicable Health and Safety regulations, must be maintained at all times.

Exit interview was conducted and report was reviewed with the applicant, Sarbaz Afhsin.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
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