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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409195
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:46:49 AM

Document Has Been Signed on 12/08/2022 11:46 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: 5DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:AFSHIN SARBAZTIME COMPLETED:
12:00 PM
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8:00AM-Licensing Program Analyst Tasha Alexander met with licensee Afshin Sarbaz for an announced ANNUAL/RANDOM AND CAPACITY INCREASE inspection. Present for the inspection were licensee, adult assistant and 9 Nurida Jabrayilova and 5 children in care consisting of 3 infants and 2 preschoolers. LPA toured the facility and front yard for a health and safety inspection. The children's files were reviewed and are complete. The home is equipped with a 3A40BC fire extinguisher, working smoke detector/carbon monoxide combo. There is a working telephone in the home, no change in phone number. Per licensee there are no fire arms on the premises. There are no pools, hot tubs, or other bodies of water at the home. All poisons, cleaning solutions and medications are inaccessible to children. Licensee and assistants have current CPR and 1st Aid training which expires 1/9/2024 respectively. The off limits areas are all 3 bedrooms and garage. Licensee was also informed of the licensing web address (www.ccld.ca.gov) for downloading child care forms and (www.myccl.com) to register to receive child care updates.
Licensee [or facility representative] 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.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SARBAZ, AFSHIN
FACILITY NUMBER: 073409195
VISIT DATE: 12/08/2022
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A review of staff records on 12/7/22 indicates that all facility staff or other individual who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Effective September 1, 2016, a person may not work or volunteer at a child care center or family child care home unless he or she has been vaccinated against pertussis, measles and influenza or has an exemption. Today, licensee and assistant have immunization records in file.

Today the newly implemented mandatory mandated reporter training course has also been discussed. all staff have up to date certificates in file. exipiration date 8/2023 and 12/2024 respectively


CONTINUED ON 809-C


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
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SARBAZ, AFSHIN
FACILITY NUMBER: 073409195
VISIT DATE: 12/08/2022
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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.

As a result of this visit, there are no deficiencies cited today. This home will be licensed for a large fcch as of today 12/8/22. Congratulations



An exit interview was conducted. A notice of site visit was posted.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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