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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313893
Report Date: 07/07/2023
Date Signed: 07/10/2023 08:12:24 AM

Document Has Been Signed on 07/10/2023 08:12 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MIRFATTAHI, SEYEDEH ZAHRAFACILITY NUMBER:
304313893
ADMINISTRATOR:MIRFATTAHI, SEYEDEH ZAHRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 545-4057
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
07/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Zahra S MirfattahiTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Araceli Bootorabi and Mila Quinto conducted a case management visit for the purpose of delivering findings on 6/29/2023 and today 7/7/2023.

Census on 7/7/2023: 0 infants – 8 Children Over 2 – 2 Adults working directly with Children – 1 Other Adults

LPAs observed upon entry on 7/7/2023 children playing in the living room and napping room.

Licensee was offered translation through Language Links upon entry and licensee declined.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

LPA Bootorabi & Quinto toured the facility on 6/29/2023 and some children observed eating on the floor or chairs. Other children were observed watching television and sleeping.

Infant Safe Sleep: Upon entry on 6/29/2023, the LPA’s asked for a census and the licensee stated she had 8 children. LPAs later heard a child crying in another room. The licensee had an infant under the age of 1 sleeping in a play yard in another room with glass doors closed and no supervision. The LPAs observed children using different play yards during the visit and children being left in different play yards for extended periods of time.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 07/10/2023 08:12 AM - It Cannot Be Edited


Created By: Araceli Bootorabi On 07/07/2023 at 11:06 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MIRFATTAHI, SEYEDEH ZAHRA
FACILITY NUMBER: 304313893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2023
Section Cited
HSC
102417(b)

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102417(b) Operation of a Family Child Care Home -The home shall be kept clean and orderly...This requirement is not met by means of the licensee's food storage (outdoor refrigerators) accumulated a significant amount of dirt and grime on its exterior and interior surfaces. The backyard
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The licensee stated she will change the refrigerator for kids and will only be using the small one. She will be shopping for kids every two weeks and clean the refrigerator or hire someone to clean it. Licensee stated she will be organizing the playground for children to use.
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 was observed to be unorderly and unsafe for children in care by means of having drills, plastic bags metal outdoor umbrellas on the ground, home improvement machinery etc. This poses a potential risk of the health and safety of children in care
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Type B
07/10/2023
Section Cited
HSC102417(g)(4)

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102417(g)(4) Operation of a Family Child Care Home: The home shall be free from defects or conditions which might endanger a child...detergents, cleaning compounds...and other items which could pose a danger if readily available to children shall be stored... inaccessible to children.
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Licensee stated she will not be puitting things on the counter or on the restroom area. She will put them outside or in the pantry so children do not reach it. The licensee will be adding this to her plan and providing a copy to LPA
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This requirement is not met by means of disinfecting wipes being accessible to children in care, hazardouse items observed in the back yard, and broke gate by front door.This poses a potential risk of the health and safety of children in care.
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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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


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Document Has Been Signed on 07/10/2023 08:12 AM - It Cannot Be Edited


Created By: Araceli Bootorabi On 07/07/2023 at 11:12 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MIRFATTAHI, SEYEDEH ZAHRA
FACILITY NUMBER: 304313893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2023
Section Cited
HSC
102425(5)

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102425(5) If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. Based on LPAs observation the licensee had an infant under the age of 1 sleeping in another room with glass doors closed shut.
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The licensee stated she will not being putting the child in a locked room. She will move the play yard if she needs too. Licensee will be adding this to her plan and sending to LPA
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This poses an immediate risk for children in care.
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Type B
07/10/2023
Section Cited
HSC102417(8)

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102417(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. Based on LPA's record review the licensee did not have an updated children roster available for review on 06/29/2023.
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The licensee will be sending LPA a current roster via email once updated. The licensee will make sure she will keep the document updated.
Type B
07/10/2023
Section Cited
HSC
102423(a)(2)

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102423(a)(2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. Based on LPAs observation some children can climb in and out of play which poses a potential risk for children in care.
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The licensee stated she will be getting mats for children to sleep in. The licensee will be sending photos to LPA.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MIRFATTAHI, SEYEDEH ZAHRA
FACILITY NUMBER: 304313893
VISIT DATE: 07/07/2023
NARRATIVE
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Posting Requirements: LPAs toured the home on 6/29/2023. The licensee did not have posting requirements in a publicly accessible area. Licensee was missing the Earthquake preparedness checklist and license. Licensee pulled her license and earthquake properness checklist from underneath the coach on 6/29/2023. On 7/7/2023 the licensee was given another consultation on the matter. Correction was made during the visit.

Children Roster: LPA Quinto requested the licensee’s updated children’s roster and the licensee was not able to provide it to LPA for review on 06/29/2023. On 7/7/2023 the licensee did not have an updated roster. A copy was provided and she began working on it.

Personal Rights: Children in care were also observed to be placed in highchairs without food. The licensee and Assistant were given a consultation by LPA Quinto on the use of highchairs. During the visit, the licensee stated “children needed to go to sleep” who were in play yards for extended periods of time LPA Quinto discussed the use of play yards with the licensee and assistant as children were observe to be left for extended periods of time in the play yards. Children were observed to lay awake in play yards, climb in/out of play yards and use different play yards during the 6/29/2023 visit.

On 06/29/2023 the licensee was consulted again on highchair usage, which should be for the purpose of facilitating safe and comfortable mealtime activities. The highchair should be appropriately designed and adjustable to support the child's posture and enable their active participation in eating and social interaction. It should not be used as a means of confinement or prolonged restriction that hinders the child's movement or physical development.

Operation of a Family Child Care Home: The LPAs toured the home on 6/29/2023 and LPAs observed disinfecting wipes in the bathroom and children’s dining table in the Living room. LPA Quinto consulted the licensee on removing the items from the children’s reach. The wooden gate upon entry that prevents children from going into the front door and kitchen area was observed to be broken. The licensee stated her husband had fixed it and the children broke it again. The wooden gate had sharp edges that pose a danger to children in care.

LPAs observed the backyard on 06/29/2023 which had hazardous items for children in care such as paint, drills, plastic bags, outdoor umbrellas laying on the floor, and other home improvement machinery. During the time of the visit, it was observed that the fence was being painted by a cleared adult in the home. The backyard was not kept clean and orderly.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MIRFATTAHI, SEYEDEH ZAHRA
FACILITY NUMBER: 304313893
VISIT DATE: 07/07/2023
NARRATIVE
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The licensee had two refrigerators outside which she stated was storage for the children in care food on 6/29/2023. The refrigerator contained expired milk, moldy fruits, and vegetables. The refrigerator had accumulated a significant amount of dirt and grime both on its exterior and interior surfaces. The exterior of the refrigerator is coated with a layer of dust and smudges. Dried liquid stains on the shelves and walls were observed inside both refrigerators to not be maintained. The bottom of the refrigerator contains a collection of food debris, crumbs, and large dark spills.

Record Review: On 07/07/2023 LPA Quinto and Bootorabi requested to review children’s files. LPA(s) reviewed children’s files for LIC9224 for type A violations, LIC 9227, and Infant Safe Sleep Logs. 5 of 5 files were missing LIC 9224, 1 of 1 files had LIC 9227, and 0 of 1 Infant Sleep Logs were observed.

LPA discussed the safe sleep regulations with the licensee 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 the 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to childcare 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

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MIRFATTAHI, SEYEDEH ZAHRA
FACILITY NUMBER: 304313893
VISIT DATE: 07/07/2023
NARRATIVE
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https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12


were observed, discussed, and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today:
102417(b), 102417(g)(4), 102425(5), 102417(8), 102423(a)(2), 102425(j)(2)

Due to the Type A violations cited today, the licensee shall post, and provide copies, of the report to parents/guardians of the children in care at the facility by the next business day and shall provide them to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. In addition, the licensee shall immediately post upon receipt of the Proof of Correction for 30 consecutive days.

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted and the report was reviewed with the licensee MIRFATTAHI, SEYEDEH ZAHRA.

Printed resources provided to licensee during today visit: Infant Safe Sleep Regulations, Safe Sleep FAQ (English & Farsi), Safe Sleep Log Sample, What Does A Safe Sleep Environment Look Like Flier, FCCH Parent Rights PUB394, Capacity Regulations for FCCH Flier, TSP brochure, OC Early Care & Education Resources & Support Agency Flier, LIC 9040 Child Care Facility Roster, LIC 311D Forms/Records To Keep in Your FCCH, LIC 9224, and 102417 Operation of Family Child Care Home.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 07/10/2023 08:12 AM - It Cannot Be Edited


Created By: Araceli Bootorabi On 07/07/2023 at 11:45 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MIRFATTAHI, SEYEDEH ZAHRA
FACILITY NUMBER: 304313893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
HSC
102425(j)(2)

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102425(j)(2)The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document ... Based on record review the licensee did not have record of infant safe sleep log. This poses an potential risk for children in care.
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The licensee stated she will send proof of completing sleep logs once the child returns to care. The LPA will send proof of completing it vial email to the LPA.
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LPA provided resources to licensee during visit.
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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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


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Document Has Been Signed on 07/10/2023 08:12 AM - It Cannot Be Edited


Created By: Araceli Bootorabi On 07/07/2023 at 01:53 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MIRFATTAHI, SEYEDEH ZAHRA
FACILITY NUMBER: 304313893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2023
Section Cited
CCR
102419(5)(g)

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102419 (5)(g) ...parents must be provided copies of the following or failure to comply with this will result in a citation...Obtain parental signature and date .. LIC 9224... as receipts in the child’s file that the parents have received copies.
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The licensee stated when parents come she will explain to parents that licensing came and ask parents to sign. The licensee stated she will be adding the LIC 9224 to each child's record.
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Based on LPA's record review the licensee did not comply by means of not having LIC9224 with parents names, ans missing LIC 9224 for 5/5/2023 visit. LPAs provided a consultation.
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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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


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