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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314044
Report Date: 08/29/2022
Date Signed: 08/29/2022 11:35:39 AM

Document Has Been Signed on 08/29/2022 11:35 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SHAHRAMNEJAD, ELAHAMFACILITY NUMBER:
304314044
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/29/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Applicant, Elham ShahramnejadTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted an announced in-person Pre-Licensing inspection for a new Small Family Child Care home. LPA met with Applicant, Elham Shahramnejad 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.
Applicant stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. Applicant was reminded if changes, to notify the licensing office. Applicant notified LPA that another adult has been added to reside at this home.

Applicant is requesting for a Small family childcare home license. Operation hours will be Monday to Friday 7:30 AM to 5:00 PM and care and supervision will be provided to children ages birth to 7 years old.

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a three story town home with 3 bedrooms, 3 full bathrooms, Living room, dinning room area, kitchen which are on the 2nd floor. Bedrooms are on 3rd floor. Day care area is on the bottom of the house.
Areas that will be used by children were inspected for safety, comfort, cleanliness, ventilation and heating. Telephone service (cell phone is the primary contact phone) .

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 garage and top cabinets. The Licensee states (that there are no poisons on the premises). Applicant was advised that any poisons must be locked with a key or combination lock.
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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: SHAHRAMNEJAD, ELAHAM
FACILITY NUMBER: 304314044
VISIT DATE: 08/29/2022
NARRATIVE
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Based on the Facility Sketch submitted, areas off limits to children and parents are: Applicant has designated 3rd level of the home, which has two bedrooms, and two bathrooms and second floor with kitchen and attached garage, living room, and dinning room and balcony as off limits on the 2nd level.

Areas Designated for Day care activities: Parents and children shall enter the home, through the main entrance door, leading to 1st floor by using the stairs. The applicant has designated the down the stairs room for day care children. There is one full bathroom, and small kitchen, and two patios on this level of the house. The designated day care area is one room which is for eating, playing, napping & reading, and day care activities. This room was observed to have age appropriate activities and Educational items for enrolled children. There is a low level queen size bed in the corner of this room which may be used for napping of older children (Preschool age). There are two pack and play for the use of children under 2 years of age. beddings are provided by the applicant. Applicant shall provide ongoing supervision during nap time.

There is a child safety gate installed at the beginning of the stairway making the second level inaccessible, Small kitchen has safety locks on the cabinets.

Garage door is on the 2nd floor which is located on the off limit area and is inaccessible to children by the baby gate which is installed at the entrance of the stairs.

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

Licensee will 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.



Licensee 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.

The applicant has provided the proof of control of property to LPA..

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
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: SHAHRAMNEJAD, ELAHAM
FACILITY NUMBER: 304314044
VISIT DATE: 08/29/2022
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The full bathroom is located in the designated room for children's use with small step stool and toddler toilet seat for the younger toddlers. There is a cabinet under the sink with safety latch installed. The children's bathroom was observed to be safe and free of hazardous items.

Applicant will provide AM/PM snacks and lunch to children. If food is brought from home and these containers shall be labelled with their names by the parents and stored accordingly.

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,

OUTDOOR PLAY AREA: Applicant will use the two patios which is located on the 1st level for back yard for outdoor activities. It is fenced with metal gates. and concrete flooring covered with soft padded carpet. It has age appropriate activity items for children in care. It is safe for outdoor activities.

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

The fire extinguisher did not meet the licensing requirements. The applicant was advised to provide the right size of 2A10 BC fire extinguisher. Smoke and carbon monoxide detectors were tested and are operable. Applicant stated he fire extinguisher will be stored in the kitchen and out of reach of children on the first floor. Smoke detector/ Carbon Monoxide is mounted on the ceiling of the passage area on the first and second level and 3rd level.



Applicant has 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 08/06/2024. 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.
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
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: SHAHRAMNEJAD, ELAHAM
FACILITY NUMBER: 304314044
VISIT DATE: 08/29/2022
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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.

Applicant 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, Elham Shahramnejad during the Exit interview:

Criminal Record statement: Applicant, Elham Shahramnejad 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.
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: SHAHRAMNEJAD, ELAHAM
FACILITY NUMBER: 304314044
VISIT DATE: 08/29/2022
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Safe Sleep : LPA discussed the safe sleep regulations with applicant, Elham Shahramnejad & 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, Elham Shahramnejad 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, Elham Shahramnejad 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. (LPA gave the LIC 311D with all the required forms and Fire logs to be maintained in the home). A packet of enrollment for children and posting forms were printed out and were given to applicant.

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: SHAHRAMNEJAD, ELAHAM
FACILITY NUMBER: 304314044
VISIT DATE: 08/29/2022
NARRATIVE
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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 not in compliance for a (Small Family Child Care Home) with Title 22 Regulations

The following corrections shall be sent to the Department before issuing a license.



(1) Installation of a Child Safety doorknob on the storage room and kitchen.
(2) The gate in the larger patio shall be sturdy and secured.
(3) Documents for association of additional adult living in the house.
(4) Right size of the fire extinguisher (2A 10 BC)
(5) LIC 279 shall be updated with the additional adult living in the house.
(6) Fire place shall be secured in the children's room.
(7) The wall of the patios shall be covered without the items of sharp nails sticking out.
(8) A picture of complete items for posing requirements.

Applicant shall submit the above corrections by September 7, 2022 to the LPA via email.
Final License shall be approved upon receiving the above corrections and final approval of the management. .
Exit interview was held with applicant, Elham Shahramnejad and appeal rights were presented.
End of report,
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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