073409195-4-17-2024-02-CC-THAR-D4ESQM-20240417140458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073409195
Report Date: 04/17/2024
Date Signed: 04/17/2024 02:05:08 PM

Document Has Been Signed on 04/17/2024 02:05 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	SARBAZ, AFSHIN		FACILITY NUMBER:	073409195
ADMINISTRATOR/ DIRECTOR:	SARBAZ, AFSHIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 497-8986
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 11	DATE:	04/17/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	AFSHIN SARBAZ		TIME VISIT/ INSPECTION COMPLETED:	02:15 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	On 4/17/2024 at 8:15am Licensing Program Analyst (LPA) Tasha Alexander met with Licensee Afshin Sarbaz for an ANNUAL/RANDOM Inspection. Present during the inspection was the Licensee, 2 assistants, Marina Sandueva, Liliya Sulemanova, seven (7) preschool age child and four (4) infants. Licensee lives in the home with his two minor children ages 15 and 16 years old. Licensee’s home was toured for a health and safety inspection. The facility operates from 8:00am – 5:30pm, Monday - Friday. ON LIMITS AREA: living room, dining room, family room, kitchen, backyard OFF LIMITS AREA: Three (3) bedrooms and Garage ISOLATION AREA: Living Room The facility is a single-story home owned by the Licensee. The inside of the home was observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee stated that he provides all food for the children. All food that may be brought from the children’s home will be properly labeled and stored. Licensee stated that he does not transport children. There are no pets. Per licensee, there are no firearms in the home. There is one (1) fully charged 3A40BC fire extinguisher in the childcare room (living room). There is one (1) working smoke alarm/carbon monoxide detector combo in the childcare room #2 (family room). The fireplace in the family room is covered by a curtain and also gated making it inaccessible to the children in care. Licensees uses low sitting type highchairs and age appropriate tables and chairs for eating. There are four play yards used for sleeping. All napping equipment is clean, well maintained and in proper working order. The home is equipped with central heat and air conditioning proper ventilation. continued on 809-C

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SARBAZ, AFSHIN	FACILITY NUMBER: 073409195
	VISIT DATE: 04/17/2024

NARRATIVE

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The backyard is fully fenced, clean and has ample age appropriate materials for the children in care. There is a storage shed in the backyard that is gated. making it inaccessible to the children. The surface of the backyard is covered with turf material. There are multiple age appropriate "little tikes" style play structures for children's play. There is a patio that provides shade. LPA did not observe any harmful bodies of water in or around the home.

Licensee is operating within their licensed capacity and is in ratio. Licensee's Health and Safety training with Lead Poisoning component has been completed. Licensee and both assistant's Pediatric CPR and First Aid training is complete and expires 12/28/25. Licensee and assistant Marina's Mandated Reporter training is complete and expires 1/2/26 and 2/16/26. LPA obtained the fire/disaster drill log, log is complete with the last drill logged 4/1/24. All adults living and working in the home have obtained a criminal record clearance. All required forms are posted in the childcare room by the entrance door. LPA obtained the children’s files, helper's file and facility roster. The children's files are complete, roster up to date.

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.
Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com

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.

Continue on 809-C

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SARBAZ, AFSHIN	FACILITY NUMBER: 073409195
	VISIT DATE: 04/17/2024

NARRATIVE

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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.

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.

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.

Exit interview conducted and report was reviewed with Licensee Afshin Sabar.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/17/2024 02:05 PM - It Cannot Be Edited

Created By: Tasha Hackett-Alexander On 04/17/2024 at 01:00 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: SARBAZ, AFSHIN	FACILITY NUMBER: 073409195
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(c)

Administration of Child Day Care Licensing

(c) Current proof of completion for each licensed child day care provider or applicant for that license, administrator, and employee of a licensed child day care facility shall be submitted to the department upon inspection of the child day care or upon request by the department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT IS NOT MET AS EVIDENCED BY A REVIEW OF RECORDS WHICH REVEALED ASSISTANT LILYA IS UNABLE TO LOCATE HER MANDATED REPORTER CERTIFICATE TODAY
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	LICENSEE WILL HAVE THE ASSISTANT LOCATE HER CERTIFICATE AND SUBMIT A COPY OF TO COMMUNITY CARE LICENSING BY 5/1/24. IF THE ASSISTANT IS UNABLE TO LOCATE THE CERTIFICATE, THE ASSISTANT MUST TAKE THE TRAINING COURSE AND SUBMIT UPDATED CERTIFICATES TO COMMUNITY CARE LICENSING BY 5/1/24.

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT IS EVIDENCED BY A REVIEW OF RECORDS WHIC REVEALED STAFF DO NOT HAVE PROOF OF UP TO DATE FLU VACCINES IN FILE, ASSISTANT LILYA DOES NOT HAVE PROOF OF THE MEASLES VACCINES IN FILE AND ASSISTANT MARINA DOES NOT HAVE PROOF OF THE PERTUSSIS VACCINE IN FILE.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	LICENSEE WILL SUBMIT PROOF OF UP TO DATE FLU VACCINES FOR HIMSELF AND STAFF AND HAVE BOTH ASSISTANTS OBTAIN THEIR IMMUNIZATION RECORDS AND SUBMIT PROOF OF MMR & TDAP TO COMMUNITY CARE LICENSING BY 5/1/24.

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:

Tasha Hackett-Alexander

LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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