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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314031
Report Date: 04/24/2023
Date Signed: 04/24/2023 04:25:59 PM

Document Has Been Signed on 04/24/2023 04:25 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, MAHSHIDFACILITY NUMBER:
304314031
ADMINISTRATOR:HABIBI, MAHSHIDFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 750-0720
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mahshid, Habibi Licensee TIME COMPLETED:
04:15 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Patricia Duron. LPA met with licensee and census was taken. There were 9 children which included 4 of infants and 5 preschool age children in day care area. 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 2 adults including the licensee and 1 minor child living in the facility. Facility Day care hours are 6:30am-6:30pm, Monday through Friday.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of baby gates. Licensee has designated second level of the home (two bedrooms and two bathrooms) as off limits. Licensee has installed child safety gates on each end of the kitchen, and second safety gate in the passage area leading to the other side of the home as this area is 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, a wooden shelf in front blocking the fire place. Day care area consist of living room, next to kitchen. A small hallway going towards bedroom and attached bathroom. Outdoor play area consists of age appropriate toys and structures and artificial grass installed in outdoor play area. Right side yard is off limits with a safety gate installed.

There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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: HABIBI, MAHSHID
FACILITY NUMBER: 304314031
VISIT DATE: 04/24/2023
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. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. The home has age appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. There are no bodies of water on the premises.

The licensee does have a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. LPA observed 1 of infant in care from 0-12 months. LPA observed and reviewed LIC 9227 Individual Infant Sleeping Plan in children’s files.

The licensee Pediatric CPR/First Aid certification expires on 5-28-2024. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee and assistant were reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.

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

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
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: 04/24/2023
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The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone 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, immunizations, Pediatric CPR/First Aid, and mandated reporter training.

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms.
The licensee was informed of the Important Updates available at www.ccld.ca.gov and may request to be added to an email list to receive Community Care Licensing Important Notifications from the above website and selecting Receive Important Updates link

A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:


English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with licensee 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.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
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: 04/24/2023
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In the areas that were evaluated, NO deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.


An exit interview was conducted 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. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.

Page 4 of 4. End of Report.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
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