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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313969
Report Date: 04/11/2023
Date Signed: 04/11/2023 01:37:37 PM


Document Has Been Signed on 04/11/2023 01:37 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:EJTEHADI, ZAHRAFACILITY NUMBER:
304313969
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
04/11/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Zahra Ejtehadi, LicenseeTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Stacy Torrence conducted a case management inspection, in response to licensee’s request for a capacity increase. LPA met with licensee Zahra Ejtehadi, who guided analyst on a tour of the facility. During today’s inspection, licensee’s assistant Fatemeh Zarafrouz was also present. LPA Torrence observed five children in the designated daycare area, and child in the sleeping room. The facility was within licensed capacity and the required ratio. Licensee stated there is currently three adults and one minor child living in the home. Licensee stated she is not currently registered with any Foster Care agency or holds a foster parent license. Licensee was reminded if changes to notify the licensing office.

A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

This is a two-story home with four bedrooms, 2.5 bathrooms, living room, family room, game room, kitchen, dining room, laundry room, front yard (not fences), backyard (fenced), and garage. Licensee has designated the game living room, one bathroom and backyard as part of the day-care. Licensee has designated entire 2nd floor, kitchen, family room, front yard, and garage, as the off-limit areas. Licensee has placed child proof safety gates at the bottom of the stairs, and at the three entrances of living room, making these areas inaccessible to the children in care. There is a sliding door at one entrance of the kitchen and a child proof gate at the other entrance, ensuring these areas are inaccessible to the children in care. The licensee acknowledged the children may never enter the off-limit areas, during operation hours. Control of property was verified by LPA during today’s inspection. The licensee has a cell phone that is used for childcare. The licensee was informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation. Licensee was informed and understands the home is to be free from smoking during hours of operation.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: EJTEHADI, ZAHRA
FACILITY NUMBER: 304313969
VISIT DATE: 04/11/2023
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The facility has a fireplace, located in the living room and family, barricaded by a glass covers and sturdy drawer. Cleaning solutions/chemicals, utensils, and sharp knives located in the kitchen, which is the off-limit area. Poisons/Hazardous items are not stored on site, and none were observed. There are no bodies of water. The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. Licensee stated there are no weapons or firearms on the premises. When firearms are present, they must be locked and stored separately from the ammunition. During today's inspection, the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged.

Licensee will use the backyard for children's outdoor activities. The back yard is appropriately fenced. LPA observed play equipment to be safe and free of hazards.

Per licensee, she will provide breakfast, lunch, and snacks for the children. LPA reminded applicant, that if food is not provided and food is brought from the children’s homes; container shall be labeled with child’s name and properly stored or refrigerated. Per licensee, parents provide diapers, wipes, and lotion for the infants. Licensee stated she use a changing table to change the infants. LPA reminded licensee to always visually supervise the infant, while changing their diapers.



Per licensee, all children will nap in the living room, on mats and play pens. Licensee stated parents will provide linen and blanket for the children.

Licensee was not in compliance with the Safe Sleep 15-minute log. Licensee stated she check the infants every 15-minutes but cannot locate the log. LPA advised licensee that all infants are required to be check every 15-minutes and documented, while sleeping, even if the infant is now sleeping on a mat or cot, and the log must be available to LPA upon inspections. There is baby monitor in the infant’s sleeping area with a camera.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 2 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: EJTEHADI, ZAHRA
FACILITY NUMBER: 304313969
VISIT DATE: 04/11/2023
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Licensee’s and Assistant’s Mandated Reporter Training were current. EMSA approved Pediatric CPR and Pediatric First Aid were current for licensee and assistant, which both expires on 10/2023 and 07/2024 respectively.

LPA advised the licensee how to access forms, regulations and quarterly updates online at: www.ccld.ca.gov.


LPA consulted and explained Child Abuse Reporting, Updated Parent’s Rights Poster with Complaint Hotline information, Never Shake a Baby, Sudden Infant Death Syndrome (SIDS), and Safe Sleeping practices.

Fire clearance granted on 03/27/2023.

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 violation of the California Code of Regulations, Title 22; Division 12, was observed and cited today: Infant Safe Sleep 102425(j)(2) (see LIC 809D).

A new license for operating a Large Family Child Care Home shall be issued upon final review and if additional information is needed, licensee shall be contacted.

An exit interview was conducted. The report was reviewed and discussed with licensee. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. The Notice of Site Visit must be posted on or adjacent to the door. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/11/2023 01:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: EJTEHADI, ZAHRA
FACILITY NUMBER: 304313969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2023
Section Cited

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102425(j)(2) Infant Safe Sleep. The provider shall supervise infants while they are sleeping and adhere to the following requirements:
The provider shall check and document the following...... This requirement is not met by evidence by:
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Per licensee, she will email the documented 15-minute check log to LPA by POC due date.
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Based on record review, the licensee did not comply with the section cited above in that licensee did not have proof of the checking every 15 minutes, while sleeping, which posed a potential health and safety risk to persons 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: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4