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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 196216832
Report Date: 01/25/2024
Date Signed: 01/25/2024 11:11:13 AM

Document Has Been Signed on 01/25/2024 11:11 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:MANSOURPOUR FAMILY CHILD CAREFACILITY NUMBER:
196216832
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
01/25/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Fahimeh MansourpourTIME COMPLETED:
11:30 AM
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On January 25, 2024 AM, Licensing Program Analysts (LPAs) Laura Villanueva and Aaliyah Zendejas conducted an announced Pre-licensing inspection. Applicant and LPAs toured the facility inside and outside. Applicant was not caring for children at the time of the inspection.

The home is a 3- bedroom, 3-bath, 2-story home. Applicant informed LPAs that a gate will be placed at the stairs. The applicant will use the family room, kitchen, 1-bathroom, and backyard for the child care. The garage, 3 -bedrooms, and 2-bathrooms will not be utilized and will be designated off limits for childcare. LPAs observed a screened fireplace in the living room and in the family room making them inaccessible to children. There are age appropriate toys, teaching materials, and furnishings in good condition and free of hazards. LPA did not observe any toxins/hazardous items accessible to children. The backyard is fully enclosed with a fenced wall. Cleaning agents and disinfectants are stored upstairs. Kitchen knives are stored out of reach. The bathroom to be used for children in care was observed to be clean and sanitary.

Because the applicant leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord.



The applicant has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 6 children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 8 children.

A regulation 2A10BC fire extinguisher was observed with a purchase date of 01/20/2024. Applicant is

CONTINUED ON LIC809C

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: MANSOURPOUR FAMILY CHILD CARE
FACILITY NUMBER: 196216832
VISIT DATE: 01/25/2024
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reminded to service or purchase the fire extinguisher yearly. LPA observed a smoke and carbon monoxide detector in the home. All adults in the home are fingerprint cleared. LPA observed the home to be orderly. No bodies of water were observed on site. Applicant stated that there are no guns or ammunition in the home.

Applicant's Pediatric First Aid/CPR certificate is valid until 03/25/2024. Applicant's Mandated Reported Training is valid until 10/15/2024. Preventative Health and Safety and Nutrition Training was completed on 12/16/2023. Child care orientation was completed on 10/31/2023.

Applicant, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a


repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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) or (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 reviewed with applicant, the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant

LPA issued the applicant updated samples of state required forms to be kept in the children's records. LPA also discussed and provided Guidelines to Safe Sleep and Effects of Lead Exposure leaflets. Applicant was provided information from PIN 20-24-CCP - Recently Approved Safe Sleep Regulations In Effect and LIC 9227 (Infant Sleeping Plan). Applicant was informed that baby walkers, jumpers, bouncers, exersaucers, or any similar article are not permitted on the premises during day care hours. Applicant was made aware of the responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.
CONTINUED ON LIC809C
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: MANSOURPOUR FAMILY CHILD CARE
FACILITY NUMBER: 196216832
VISIT DATE: 01/25/2024
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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/inspection-process.

LPA discussed the safe sleep regulations with [applicant, licensee, or facility representative]


and discussed the Child Care Licensing Safe Sleep webpage at:
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/
safe-sleep, as an additional resource. LPA also informed [applicant, licensee, or
facility representative] 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

On this date, 01/25/2024, the California Attorney General - Megan’s Law website was searched


for information on sex offenders required to register with local law enforcement under
California's Megan's Law. No registered sex offenders were found at the facility addresses.
Under state law, some registered sex offenders are not subject to public disclosure; therefore,
they may not have been included in this search. However, the Department conducts a monthly
cross reference of each address on record for all registered sex offenders against all CCLD
facility addresses pursuant to information shared by California DOJ.

Applicant, was informed of the MyChildCarePlan.org site, a consumer education


website that helps families obtain child care by connecting them to child care providers and
Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities,


providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly
Update Newsletters and other important information communication platforms.
To receive important licensed related information to licensed facilities, visit the CCLD Important
Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/
subscribe and select the Child Care option to receive email communication.

CONTINUED ON LIC809C

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: MANSOURPOUR FAMILY CHILD CARE
FACILITY NUMBER: 196216832
VISIT DATE: 01/25/2024
NARRATIVE
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care- licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the applicant, Fahimeh Mansourpour.
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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