304314031-8-8-2022-06-CC-KDEI-CH4SQ5-20220808140408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314031
Report Date: 08/08/2022
Date Signed: 08/08/2022 02:04:26 PM

Document Has Been Signed on 08/08/2022 02:04 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: 6	DATE:	08/08/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Licensee Ms. Habibi, Mahshid		TIME COMPLETED:	02:15 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	A Case Management (Licensee initiated) inspection for a change in capacity was conducted at the facility by Licensing Program Analyst (LPA), Desai, Ketki. LPA observed licensee Ms. Habibi, Mahshid caring for 2 Infants and 4 Preschool age children between the ages of 3-4 years old. Licensee has been a care provider for a Small Family child care home since February 2020, qualifying her to be a Large Family child care provider. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are two adults residing in the facility. Licensee stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. She was reminded if changes to notify the licensing office. Per Licensee, operation hours will be Monday to Friday, 6.30 AM to 6.30 PM, care and supervision shall be provided to children ages 3 months to 5 years of age (Infants to Preschool age children only). During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. 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. (1)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

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: 08/08/2022

NARRATIVE

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Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children.

Off Limit areas: 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.

Designated Day care area: Parents and children shall enter the home, through the left side gate leading into the back yard. A ring bell has been installed, on the side door which remains locked during operating hours. The side entrance gate is the official pick up and drop off area. There is an A/C unit with a covered top. Licensee has placed a child fencing across the yard, this way leads to the back yard and the sliding door opens 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. Both the rooms were observed to be well lighted with proper ventilation and air flow.

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 provides 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. (2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

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: 08/08/2022

NARRATIVE

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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

Outdoor activity area: Licensee continues to use the open back yard for outdoor activities. It is fenced with concrete and grass flooring. It is safe for outdoor activities. Licensee also also now fenced left area and left side yard with a a fence barrier making the left side inaccessible to children. LPA observed several age appropriate activities arranged in the back yard.

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

Licensee has one small pet dog, which remains 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.

(3)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

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: 08/08/2022

NARRATIVE

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LPA verified there is a working telephone service (cellular service) in the home.

The licensee does have a current roster of children in care and the 5 records were reviewed on today's inspection, LPA reviewed the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance.

The licensee holds a valid Pediatric CPR/First Aid certification is valid through May 2024 and have completed the required Mandated Reporter Child Abuse training.
Licensee also has conducted Emergency fire and earthquake drills, last drill conducted in June 2022.

LPA verified the Control of Property (Rental Agreement) and a Landlord signed consent LIC 9149 is on file for a Large Family Child Care home.

The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization's, Pediatric CPR/First Aid, and mandated reporter training.

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

OTHER INFORMATION AND FORMS PROVIDED:
Capacity Handout for a Large Family Child Care Home was provided and LIC 9150 was reviewed with the Licensee

Fire inspection from Orange County Fire Authority Fire inspection services have granted the fire clearance with specific instruction where garage and the second level is not permitted for Day care.

(4)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

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: 08/08/2022

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

Criminal Record statement: Licensee 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 Licensee 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 Licensee 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 Licensee 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.

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.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

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: 08/08/2022

NARRATIVE

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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

The facility was complying with Title 22 Regulations at the time of inspection.

LPA discussed the ratio for the Large Family Child Care home with the Licensee: Large Family Child Care Home, and with an assistant provider, may provide care for more than 12 and up to 14 children when one child is enrolled in and attending kindergarten (including transitional kindergarten) or elementary school, and another child is at least six years old, and no more than three infants are in care.

( Poster given to the Provider)

On today’s inspection each child was observed to have a safe, healthful and comfortable accommodation furnishing and equipment’s.

A license with the change in capacity for 14 children (Large Family Child care home) will be issued after final review, in the event additional requirements are needed, Licensee will be notified.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

A copy of this report and Appeal rights were presented to the Licensee.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

LIC809 (FAS) - (06/04)

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