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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020827
Report Date: 01/07/2022
Date Signed: 01/07/2022 03:47:31 PM

Document Has Been Signed on 01/07/2022 03:47 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:SHAESTEH FAMILY CHILD CAREFACILITY NUMBER:
198020827
ADMINISTRATOR:SHAESTEH, JUDITHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 995-8104
CITY:LOS ANGELESSTATE: CAZIP CODE:
90036
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
01/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Applicant, Judith ShaestehTIME COMPLETED:
03:45 PM
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This was an announced pre-licensing inspection conducted by Licensing Program Analyst (LPA) Mireya Garcia. Due to COVID- 19 precautionary measures were taken, individuals present during inspection wore appropriate personal protective equipment. Applicant, Judith Shaesteh, is requesting to operate a Large Family Child Care Home.

LPA Garcia confirmed with applicant those who will reside in the home will be two (2) adults; herself and her husband. Per applicant operation hours will be Monday to Friday from 8:00 am to 5:00 p.m. Ages to care for will be from 18 months- 5 years old. At 2:04 p.m., LPA Garcia toured through the interior of the home. This is a duplex one-story home which consists of two (2) bedrooms, two (2) restrooms, living room (main daycare area), kitchen/dining room, detached garage, shared front yard (unfenced), and backyard (fenced). (LPA observed a connecting door in the hallway that leads to the next-door property 627 N. Alta Vista. Based on LPA observation and applicant disclosure the door was observed to be inaccessible via bolt (picture was taken). In addition, based on LPA observation of shared front yard and applicant written declaration obtained applicant states, upon occupancy of next door (address 627) residents will be fingerprinted associated with facility.)

Report continues on next page 1 of 6.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SHAESTEH FAMILY CHILD CARE
FACILITY NUMBER: 198020827
VISIT DATE: 01/07/2022
NARRATIVE
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All areas identified on the facility sketch were inspected. Areas that are accessible to daycare children will be the two (2) bedrooms, two (2) restrooms, living room (main daycare area), kitchen/dining room, and backyard (fenced). Based on the Facility Sketch submitted, areas off-limits to children and parents will be the shared (unfenced) front yard and detached garage.

**Rooms that are off-limits need to be made inaccessible during operating hours** The Applicant does understand that licensing staff may have access to off-limit areas during inspection visit if necessary.

LPA did not observe any hazards inside the home. LPA asked to be shown the electrical outlets in the areas used by the children and observed to be covered. Detergents, cleaning compounds, medicines, sharp objects, and hazardous items that can pose a danger to children was observed inaccessible in areas designated for children. The Applicant states that there are no poisons in the home. The Applicant was advised that any poisons must be locked with a key or combination lock. LPA also observed appropriate equipment, toys, and games for children.

The value on the 2A10BC fire extinguisher indicates fully charged. Per applicant, she purchased the fire extinguisher during 06/2021. LPA advised applicant to always maintain a copy of the receipt of purchase for the fire extinguisher. There is a first aid kit located in the kitchen. There are smoke detectors throughout the home and a carbon monoxide detector located in the two (2) bedrooms and in hallway. At 2:17 p.m., LPA Garcia tested both alarms and found them to be operational. At 2:19 p.m.., LPA Garcia toured through the exterior of the home. The back yard will be used for daycare outdoor play. LPA observed the back-yard area to be fenced, a pad lock was observed to be placed on backyard gate that separates entry to 627 (picture was taken). Applicant states, the rear side of back yard will be kept lock to prevent potential residents from 627 to have access to the backyard, LPA obtained declaration from applicant. There are age-appropriate toys and play equipment on site.

Report continues on next page 2 of 6.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SHAESTEH FAMILY CHILD CARE
FACILITY NUMBER: 198020827
VISIT DATE: 01/07/2022
NARRATIVE
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Per Applicant, there are no pets, no firearms, weapons, or bodies of water on the premises.

The applicant states she will provide food for children in care. Applicant was advised that if food is brought from the children’s homes, all containers must be labeled with child’s name and properly stored or refrigerated.

The applicant has completed the required Health and Safety Training, Nutrition Training, and Pediatric First Aid and CPR. The applicant has completed the required Mandated Reporter Training.

The following was discussed with the applicant:


-Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalty will be assessed if not in compliance.
-In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated with the facility license.
-A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
-Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated.
-The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

Report continues on next page 3 of 6.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SHAESTEH FAMILY CHILD CARE
FACILITY NUMBER: 198020827
VISIT DATE: 01/07/2022
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-Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes, and/or if you move from your home.
-Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. (use LIC624B for written report)
-Fire and safety drills must be performed every six months and documented for review by the Department.
-Smoking is prohibited in a family child care home.
-Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
- No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines, and any other item that falls into that category are not permitted in the facility.
-All adults living and working in the home shall be made aware of the Department's right to inspection authority, which includes but is not limited to the right to enter the home when children are being cared for, interview children and adults, and review documentation.
- Licensees shall reveal each facility license number in all advertisements, publications, or announcements with the intent to attract clients.
- Emergency Disaster Plan, Parent’s Rights Poster, and the Facility License are required to be posted.

Infant Care: Applicant states that at this time she does not plan to care for infants however will provide infant care if the need arises. LPA did not observe any infant equipment during this inspection. Licensing staff advise if the applicant does decide to care for infants to sleep infants where they can be directly supervised and advised against sleeping infants in a separate room. Infants under 12 months should sleep mouth up, on their backs, free of clutter surrounding their sleeping space.

Report continues on next page 4 of 6.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SHAESTEH FAMILY CHILD CARE
FACILITY NUMBER: 198020827
VISIT DATE: 01/07/2022
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LIC 9227 (Individual Sleeping Plan) for infants up to 12 months and PIN 20-24-CCP: Recently Approved Safe Sleep Regulations in Effect was explained and issued to the applicant. Title 22 Regulation Section 102425(j) Infant Safe Sleep was discussed with the applicant, including but not limited to documentation that shall be maintained.

Medication: 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Per Applicant, she will inquire about obtaining liability insurance or a bond in accordance with the standard established by the Family Child Care statute. The law requires a Family Child Care provider to carry liability insurance or bond in the amount of $300,000 annually or to maintain the signed statement in the facility file. Signed statements (LIC282) shall be in the children’s files.

LPA Garcia consulted and explained Child Abuse Reporting, Effects of Lead Exposure Flyer, Updated Patent’s Rights Poster with Complaint Hotline information, Capacity Handout (Small & Large) was provided during this inspection. LPA Garcia advised the applicant how to access forms, regulations and quarterly updates, and Provider Information Notices (PIN) on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms: Children forms/records, Facility forms/records, facility forms/ records, and Information to be posted in the Family Child Care Home. Report continues on next page 5 of 6.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SHAESTEH FAMILY CHILD CARE
FACILITY NUMBER: 198020827
VISIT DATE: 01/07/2022
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During this inspection, Licensing staff consulted with applicant regarding COVID-19 health and safety guidelines on this date. LPA Garcia provided applicant with a copy of Health Officer Order for the Control of COVID-19: Publix Health Emergency Quaratine Order revised 12/31/21. LPA Garcia observed COVID-19 postings posted throughout the facility (outdoor front entrance/indoors) where visible. Per applicant, the following safety precautionary measures will be taken during the pickup and drop off of children: Children will be pick up and drop off in front of the home where daily health checks; temperature checks and screening upon entry will be conducted by day care staff.

At this time, the licensee home meets the description of a safe and healthy environment for children as described in Chapter 1, Division 12, Title 22 of the California Code of Regulations, and will be submitted for approval to be licensed as a Large Family Child Care Home. There is an approved fire clearance on file. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

At 3:45 p.m., an exit interview conducted and report was reviewed with Applicant, Judith Shaesteh.

Report ends here page 6 of 6.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6