304314063-8-30-2022-06-CC-MMAK-CHSSLJ-20220830135826

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314063
Report Date: 08/30/2022
Date Signed: 08/30/2022 01:58:37 PM

Document Has Been Signed on 08/30/2022 01:58 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:	NIKBAKHSH, BAHAREH		FACILITY NUMBER:	304314063
ADMINISTRATOR:	NIKBAKHSH, BAHAREH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 473-0777
CITY:	IRVINE	STATE: CA	ZIP CODE:	92618
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	08/30/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Applicant		TIME COMPLETED:	02:30 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	Page 1 of 6 Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted an announced in-person Pre-Licensing inspection for the purpose of licensee's relocation. Licensee was licensed under 304313983 for a small family child care and has been re-located to this address for a large family child care home. LPA met with applicant, Bahareh Nikbakhsh 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 is requesting for a large family childcare home license. Operation hours will be Monday to Friday 7:00 AM to 5:30 PM and care and supervision will be provided to children ages one month old to 5 years old. 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 full bathrooms, and balcony on the 2nd floor. Two rooms, kitchen, children's' bathroom, garage, and backyard are located on the 1st floor. Areas that will be used by children were inspected for safety, comfort, cleanliness. Ventilation and heating were central heat in the home. in front of it making it inaccessible to children. Telephone service (cell phone is the primary contact phone. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger Continued on page 2

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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: NIKBAKHSH, BAHAREH	FACILITY NUMBER: 304314063
	VISIT DATE: 08/30/2022

NARRATIVE

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to children are inaccessible in areas designated for children stored in the locked 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.

Based on the Facility Sketch submitted, areas off limits to children and parents are: Applicant has designated second level of the home, which has three bedrooms, and two bathrooms, and garage as off limits on the first level. There is a child safety gate installed at the beginning of the stairway making the second level inaccessible, kitchen is open. There are 2 baby gates installed on both side of the entrance of the kitchen making it inaccessible to children.
Garage door is next to the children's bathroom, it has two locks on it making it inaccessible to children. 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.

Areas Designated for Day care activities: Parents and children shall enter the home, through the main gate, opening into the hallway of the home. The designated day care area is one bedroom for napping and one room for children's activities. Children's room was observed to have age appropriate activities and educational items for enrolled children. Learning, and dining activity will be held in the children's room. The sliding door in the children's area opens into the back yard which was concrete flooring covered with turf. with age appropriate toys, small slide and small swing with padded turf cushioning.

All children shall nap in the designated Napping room. There are 4 pack and play equipment for children under 24 months. Children over 2 years old will nap on the cots. Sheets are provided by the applicant. Applicant shall provide ongoing supervision during nap time. LPA reminded the applicant that the bedroom door for napping shall not be closed during children's napping when children under 24 months old are present unless and adult stays in the room during nap time. Continued on page 3 (

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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: NIKBAKHSH, BAHAREH	FACILITY NUMBER: 304314063
	VISIT DATE: 08/30/2022

NARRATIVE

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The bathroom is located in the passage area, close to the napping room, it is a full bathroom, with small step stool and toddler toilet seat for the younger toddlers. There is a cabinet under the sink. The children's bathroom was observed to be safe and free of hazardous items.

Applicant will provide AM/PM snacks and lunch to the 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 back yard for outdoor activities. It is fenced with concrete flooring covered with padded turf. It has age appropriate activity items for children in care. It is safe for outdoor activities.

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

There is a cat living in the house that was observed living on the 2nd level of the home.

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. Applicant has mounted the Fire extinguisher on the side wall of the entrance door. Smoke detector/ Carbon Monoxide is mounted on the ceiling of the passage area on the first and 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 08/26/2023. 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: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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: NIKBAKHSH, BAHAREH	FACILITY NUMBER: 304314063
	VISIT DATE: 08/30/2022

NARRATIVE

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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, Bahareh Nikbakhsh during the Exit interview:

Criminal Record statement: Applicant, Bahareh Nikbakhsh 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: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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: NIKBAKHSH, BAHAREH	FACILITY NUMBER: 304314063
	VISIT DATE: 08/30/2022

NARRATIVE

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Safe Sleep : LPA discussed the safe sleep regulations with applicant, Bahareh Nikbakhsh & 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, Bahareh Nikbakhsh the 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, Bahareh Nikbakhsh 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 Drill logs to be maintained in the home)

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

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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: NIKBAKHSH, BAHAREH	FACILITY NUMBER: 304314063
	VISIT DATE: 08/30/2022

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 and Large Family Child Care Home. LPA explained the age requirements for the enrolled children ensuring that when there are 8 or 14 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 (Large Family Child Care Home) with Title 22 Regulations

The following corrections shall be done before issuing a license.

(1) Association of adults to the new license by sending LIC 9182, LIC 508, and Picture ID to LPA via email.

(2) A picture of completed posting requirements.

(3) Proof of TB test clearance for applicant.

Applicant shall submit the above corrections by September 7, 2022 to LPA via email.

Final License shall be approved upon receiving the above corrections and management's review.

Exit interview was held and appeal rights were presented.
End of reports.

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC809 (FAS) - (06/04)

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