304314031-6-8-2022-06-CC-KDEI-CF5TVY-20220606150444

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314031
Report Date: 06/06/2022
Date Signed: 06/08/2022 01:06:51 PM

Document Has Been Signed on 06/08/2022 01:06 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:	HABIBI, MAHSHID		FACILITY NUMBER:	304314031
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	06/06/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Licensee Ms. Habibi, Mahshid		TIME COMPLETED:	03:30 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	Licensing Program Analyst (LPA) Desai, Ketki conducted an announced in-person Pre-Licensing inspection for Relocation of a Small Family Child Care home. LPA met with the Licensee Ms. Habibi, Mahshid who provided a tour of the new home. A review of the Facility Personnel Report Summary indicates adult residents, who require caregiver background check clearances, transfers, exemptions have been obtained and they are cleared. Licensee stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. Licensee was reminded if changes, to notify the licensing office. Application was for Relocation requesting for a Small family childcare home license. Operation hours will be Monday to Friday 6:30 AM to 6:30 PM and care and supervision shall be provided to children ages 3 months to 5 years only ( Infants to Preschool age children only) All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a two story family home with 3 bedrooms, 2 and half bathrooms, family room, living area with dining area, kitchen, laundry room, attached garage and back yard with two side yards. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone is the primary contact phone. Ventilation and heating. There is central heat in the home. Home has ceiling vents for air flow. The A/C unit is side yard ( inaccessible to children) Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children stored in the locked laundry room. The Licensee states (that there are no poisons on the premises). Licensee was advised that any poisons must be locked with a key or combination lock. (1)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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: HABIBI, MAHSHID	FACILITY NUMBER: 304314031
	VISIT DATE: 06/06/2022

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Based on the Facility Sketch submitted, areas off limits to children and parents are: Licensee has designated second level of the home (two bedrooms and two bathrooms) as off limits and on the first level, living with dining area, half bathroom, laundry room, attached garage and kitchen as off limit areas. Licensee has installed child safety gates on end of the kitchen, and second safety gate in the passage area leading to the other side of the home as off limits to the children in care. Stairway in the home is in the off limit area. Day care room has a fire place with a proper barrier in front ( two child safety strips and a wooden furniture in front blocking the fire place). Areas on the other side of the safety gate( Living with dining area/ laundry room/ kitchen/ half bathroom and garage door) Right side yard is off limits with a safety gate installed.

During the Pre-licensing inspection, LPA observed the designated off limits areas were closed and locked.

The applicant shall use the Cell phone for Day care activities and applicant was informed if a cell phone is used for child care, it must remain on the premises at all times during hours of operation.

Applicant was informed and understands the home is to be free from smoking during hours of operation.
Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Areas Designated for Day care activities: Parents and children shall enter the home, through the left side gate leading into the back yard, the side entrance gate is the official pick up and drop off area. There is a sliding door opening into the family room the designated Day care room and adjoining to it is another bedroom designated for infant care, which was observed to have the required Infant items. Licensee has designated the family room for Toddlers and Preschool age children. This room has age appropriate furniture, toys and educational items. Licensee has covered the wooden floor with thick placement mats.

Adjoining bedroom is for Infants and it also has an attached bathroom for day care children. Older infants, Toddlers and Preschool age children shall nap on Cots, linens and blankets shall be brought from home, washed on a weekly basis by the parents. Dining activities shall be held on the day care area, where licensee has placed an age appropriate table and chairs for the toddlers and preschool age children. Infants shall use high chairs which are arranged surrounding the dining table.

Infant room was observed to have napping items, including changing table/ high chair, Infant items: diapers / wipes/ lotions and milk shall be provided by the parents. Mother's milk shall be labeled and stored appropriately. Per Licensee infants shall not be left unattended while they are sleeping. (2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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: HABIBI, MAHSHID	FACILITY NUMBER: 304314031
	VISIT DATE: 06/06/2022

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LPA's discussed the Safe Sleep practice with the Licensee Ms. Habibi, Mahshid

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with applicant the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used if they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.
Licensee shall maintain LIC 9227 form in the infant file. ( Printed and given to the applicant)

Hard copy and link of Child Care Providers Guide to Safe Sleep provided to licensee on this day: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

The bathroom is located in the infant room, it has a changing table along with small step stool and toddler toilet seat for the younger toddlers. There is a cabinet under the sink with a safety lock installed. The children's bathroom was observed to be safe and free of hazardous items.

Licensee shall provide Breakfast, AM/PM snacks, lunch if food is brought from home and these containers shall be labelled with their names by the parents and stored accordingly. Licensee has been enrolled in the food program.

Upon entrance through the designated main door of the home, applicant shall receive the children here, due to pandemic parents are encouraged to follow CDC guidelines, upon entrance temperatures shall be checked, hands shall be sanitized, before children are guided into the designated day care areas.

Applicant has set up a sanitizing station at the entrance door of the house, on a side table. (3)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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: HABIBI, MAHSHID	FACILITY NUMBER: 304314031
	VISIT DATE: 06/06/2022

NARRATIVE

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OUTDOOR PLAY AREA: Licensee shall use the open back yard for outdoor activities. It is fenced with concrete and grass flooring. It is safe for outdoor activities.

There are no firearms, weapons, bodies of water in the home.

Licensee has one small pet dog, which shall remain in the off limit areas during hours of operation.

The value on the 2A10 BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable. Licensee has mounted the Fire extinguisher on the side wall of the day care room. Smoke & Carbon Monoxide detectors are mounted on the ceiling of the passage area on the second level

Applicant have completed the required Mandated Reporter Child Abuse training, Health and Safety training with Nutrition and Lead Poisoning component and Pediatric First Aid and CPR which is valid through 05/28/2024. There are first aid supplies available.

The following was discussed with the applicant: 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 Pediatric First Aid and CPR certification, TB clearance along with a valid criminal record clearance associated to the facility license.
Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated. The fire extinguisher type 2A-10 BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
Reporting Requirements: 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.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Fire and safety drills must be performed every six months and documented for review by the Department. Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

No smoking, No Johnny jumpers, No Baby walkers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility. (4)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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: HABIBI, MAHSHID	FACILITY NUMBER: 304314031
	VISIT DATE: 06/06/2022

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Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.
LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

LPA discussed the following items with the applicant Ms. Habibi, Mahshid during the Exit interview:

Criminal Record statement: Applicant Ms.Habibi, Mahshid 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.

Safe Sleep : LPA discussed the safe sleep regulations with applicant Ms. Habibi, Mahshid & 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 of the applicant Ms. Habibi, Mahshid 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.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: 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)/ (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.

Review of records to be maintained : LPA reviewed with applicant Ms. Habibi, Mahsid 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. (5)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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: HABIBI, MAHSHID	FACILITY NUMBER: 304314031
	VISIT DATE: 06/06/2022

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Subscribe to CCLD important information
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 platform. To receive important license- 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 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.

OTHER INFORMATION AND FORMS PROVIDED: Capacity Handout for a Small Family Child Care Home. LPA explained the age requirements for the enrolled children ensuring that when there are 8 children, at least one child is enrolled in Kindergarten or 6 years old, to be in compliance with Title 22 requirements and additional forms were given to the applicant.

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

The facility at the time of Pre-licensing inspection is in compliance for a (Small Family Child Care Home) with Title 22 Regulations. License shall be issued upon Management approval.

Exit interview conducted with the Applicant Ms. Habibi, Mahshid this report was read to the applicant and Appeal rights were presented.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC809 (FAS) - (06/04)

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