304314213-7-28-2023-06-CC-STOE-CU6SAG-20230728134218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314213
Report Date: 07/28/2023
Date Signed: 07/28/2023 01:42:37 PM

Document Has Been Signed on 07/28/2023 01:42 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:	MAHDIPOUR SHAMLOO, MASOUMEH		FACILITY NUMBER:	304314213
ADMINISTRATOR:	MAHDIPOUR S. M.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 899-3946
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	07/28/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:06 PM
MET WITH:	Mahdipour Shamloo, Masoumeh, Applicant		TIME COMPLETED:	01:50 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	On 7/28/2023, Licensing Program Analyst (LPA) Stacy Torrence conducted an announced, in-person Pre-Licensing inspection on today’s date due to receiving an application on 06/15/2023 requesting a location change. Applicant has requested to relocate her Large Family Childcare from 9 Foxglove Way, Irvine, to 83 Seton Road, Irvine. The LPA met with applicant Masoumeh Mahdipour, who provided a tour of the home. A review of the Facility Personnel Report Summary indicates three adults live in the home. The adult residents received caregiver background check clearances or exemptions as required by the Department. Per the applicant, there are no minor child living in the home. The applicant stated that she is not registered with any Resource Foster Care agency and that she does not hold a Resource foster parent license. The applicant was reminded to notify the licensing office of any changes. The applicant is requesting a Large Family Childcare Home license. Per the applicant, operation hours will be Monday through Friday, 7:30 AM- 6:00 PM. Care and supervision will be provided to children ages newborn to 5 years old (infants). For the purposes of licensing, an infant is defined as any child 0 to 24 months of age. All areas on the Facility Sketch LIC999 were inspected, including but not limited to, off-limits areas. The facility is single-story home with 2 bedrooms, 1 bathroom, a living room, a kitchen, a dining area, laundry room, front yard (fenced), backyard (fenced), and garage. There is a fireplace in the living room, barricaded by a bolted plywood. There are no stairs in the home. Based on the Facility Sketch LIC999 submitted, areas off-limits to children and parents are as follows: Applicant has designated one bedroom, kitchen, laundry room, and garage, as the off-limit areas. The applicant has child-proof safety gates, at both entrances of the kitchen, ensuring this area is inaccessible to the children. The applicant has child proof safety doorknobs on both of the bedroom doors, ensuring the area is inaccessible to the children in care. The applicant has a child proof safety doorknob on the laundry door, ensuring this area is inaccessible to the children in care. The applicant has a lock on the garage door, making this area inaccessible.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: MAHDIPOUR SHAMLOO, MASOUMEH	FACILITY NUMBER: 304314213
	VISIT DATE: 07/28/2023

NARRATIVE

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The applicant understands that licensing staff may have access to off-limits areas during inspection visits if necessary.

Areas Designated for Day Care Activities: The applicant has designated the living room, dining area, one bedroom, and bathroom as the day care areas.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation, and heating. The children’s bathroom was observed to be safe and free of hazardous items. The applicant has a small step tool in the children’s bathroom. The designated childcare areas were observed to have age-appropriate toys and educational items.

Detergents, cleaning compounds, medicines, sharp objects, and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant stated that there are no poisons on the premises and LPA did not observe any. The applicant was advised that any poisons must be locked with a key or combination lock. The applicant stated that there are no weapons or firearms on the premises. The LPA informed the applicant that when firearms are present, they must be locked and stored separately from the ammunition per CCR 102417(g)(4)(C).

The pressure gauge on the 2A-10BC fire extinguisher(s) indicates fully charged, as indicated on the service tag observed. Smoke and carbon monoxide detectors were tested and are operable. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

Per applicant, there are no animals in the home.

THERE IS OUTDOOR PLAY AREA: Outdoor play activities will be conducted in the backyard, which is appropriately fenced. LPA observed age-appropriate toys and equipment free from hazards. There is a community pool, approximately 200 ft from the home, which meets Title 22 102417.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: MAHDIPOUR SHAMLOO, MASOUMEH	FACILITY NUMBER: 304314213
	VISIT DATE: 07/28/2023

NARRATIVE

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The applicant stated she will provide food for the children. The applicant was informed that if children bring food from home, the children’s names must be labeled on their lunch bags and refrigerated/stored properly.

Per the applicant, children will nap in the bedroom. Children will nap on mats and infants in play yards. The licensee understands that there shall be one play yard for each infant who is unable to climb out of the crib or play yard.

The applicant stated she will provide linens and blankets for napping. The applicant stated that parents will provide diapers, lotion, wipes, and formula for the infants. Per the applicant, she will use a mat on the floor to change to the infants’ diapers. LPAs advised the applicant to always supervise at all times infants when changing their diapers.

A records review indicates the applicant has not completed the required Health and Safety Training with Nutrition and Lead Poisoning components. The applicant has a current Pediatric First Aid and CPR certification that expires on 5/21/2024. A first aid kit is available at the facility.

Per the applicant, there are no dual licenses at this address. The applicant’s email address was obtained during this inspection. The applicant was advised that the email address may be public information.

The applicant will receive children at the front door. Per the applicant, upon arrival children’s temperature will be taken, their hands will be sanitized, and the children will be taken to the designated day care area by the applicant. COVID-19 guidelines and precautions were discussed with the applicant.

In the absence of the licensee, a qualified adult must be present to supervise the children—a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification, TB clearance and immunization, and valid criminal record clearance that is associated with the licensed facility.

Annual fees must be paid by the due date, or a late fee shall be assessed and/or the License may be terminated.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: MAHDIPOUR SHAMLOO, MASOUMEH	FACILITY NUMBER: 304314213
	VISIT DATE: 07/28/2023

NARRATIVE

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The Child Advocacy Program was discussed with the applicant. The applicant was advised to register for the program to receive quarterly reports and other information in a timely manner. To register email ChildCareAdvocatesProgram@dss.ca.gov.

Reporting Requirements:

1. Changes should be reported to the Department as soon as they occur, such as construction, remodeling, telephone number changes, and/or moving out from your home.
2. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
Each family childcare home must conduct fire drills and disaster drills at least once every six months. The licensee must document the date and time of each drill. This documentation must be kept at the facility for review by the Department.

No smoking, No Johnny jumpers, No saucer chairs: any other items that fall into that category are prohibited in the facility.

Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection authority, which includes but is not limited to the right to enter the house when children are being cared for, interview children and adults, and review documentation.

Licensees must post each facility license number in all advertisements, publications, or announcements with the intent to attract clients.

H&S 1597.622: Commencing September 1, 2016, 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. The applicant has submitted proof of immunizations.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: MAHDIPOUR SHAMLOO, MASOUMEH	FACILITY NUMBER: 304314213
	VISIT DATE: 07/28/2023

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Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors, and employees must complete training as specified on mandated reporter duties. Training is available at www.mandatedreporterca.com. The applicant has completed the required mandated reporter training. Recertification is required every two years.

Incidental Medical Services Plan (IMS): The Incidental Medical Services (IMS) policy was discussed. A link to PIN 22-02-CCP was provided here: PIN 22-02-CCP: Best Practices Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child. When IMS are provided, a Plan for Providing IMS must be submitted to the Department. The applicant plans to store the medication in the kitchen, in a cabinet above the countertop, or in the refrigerator if needed.

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

The Community Care Licensing Division (CCLD) regularly sends information to providers and stakeholders via Provider Information Notices (PIN), Program Quarterly Updates Newsletters, and other communication platforms. To subscribe for updates, visit https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe.

The LPAs advised the applicant(s) on how to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.cdss.ca.gov/inforesources/community-care-licensing. LPA reviewed and issued the LIC311D “Forms/Records to Keep in Your Family Child Care Home” and provided the forms below.

Note: Children and Staff records must be kept and updated as necessary and must be available for review by the Department.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

Page: 5 of 8

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: MAHDIPOUR SHAMLOO, MASOUMEH	FACILITY NUMBER: 304314213
	VISIT DATE: 07/28/2023

NARRATIVE

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CHILDREN FORMS/RECORDS - Children’s files must contain the following completed documents and information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Affidavit Regarding Liability Insurance (LIC 282), Parent Notification Additional Children in Care (LIC 9150), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), California School Immunization Record (CDPH 286), Individual Infant Sleeping Plan (LIC 9227), Risk and Effects of Lead Poisoning (PUB 515), Family Child Care Consumer Awareness Information (LIC 9212), Blood Glucose Testing Consent/Verification (LIC 9222), Nebulizer Care Consent/Verification (LIC 9166), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Unusual Incident/Injury Report (LIC 624B), Child Care Facility Roster (LIC 9040), Property Owner/Landlord Notification (LIC 9149), Property Owner/Landlord Consent (LIC 9149), Entrance Checklist – Family Child Care Homes (LIC 126), Forms/Records to Keep In Your Family Child Care Home (LIC 311D), Safe Sleep Flyer-What Does A Safe Sleep Environment Look Like?, Never Ever Shake A Baby Brochure.

STAFF FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records as specified in Title 22 Regulations 102416.1, Notice of Employee Rights (LIC 9052), one Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) per provider, Copy of Pediatric Cardiopulmonary Resuscitation & Pediatric First Aid (CPR & First Aid Certification), Proof of pertussis, measles, and Tuberculosis (TB) vaccines, Proof of influenza vaccine (or documentation of exemption), Proof of Mandated Reporter Training certificate, Copy of Criminal Background Clearance Transfer Request (LIC 9182), Copy of Criminal Record Exemption Transfer Request (LCI 9188).

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: MAHDIPOUR SHAMLOO, MASOUMEH	FACILITY NUMBER: 304314213
	VISIT DATE: 07/28/2023

NARRATIVE

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INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by law to post the following:
Facility License (LIC 203), Waivers (if applicable), Notification of Parent’s Rights Poster (PUB 394), Earthquake Preparedness Checklist (LIC 9148), Emergency Disaster Plan (LIC 610A) California Car Seat Law (PUB 269). ). A Notice of Site Visit (LIC 9213) must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
Capacity Handouts for a Small Family Child Care Home and Large Family Child Care Home were provided.

The following was discussed with the applicant:
The licensee understands that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption prior to initial presence in a licensed facility. Violation of this requirement will result in a citation and civil penalties of one hundred dollars ($100) per violation, per day for a maximum of five (5) days for a first offense. Subsequent violations will result in civil penalties for a maximum of thirty (30) days in accordance with Section 1596.871 of the Health and Safety Code.

LPA discussed the safe sleep regulations with the applicant and 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. LPAs also informed the applicant of 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.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: MAHDIPOUR SHAMLOO, MASOUMEH	FACILITY NUMBER: 304314213
	VISIT DATE: 07/28/2023

NARRATIVE

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Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

Fire Clearance was granted on 07/18/2023.

The facility was in compliance for a Large Family Child Care Home with Title 22 Regulations, in regard to physical plant; however, the applicant is pending the Health and Safety with Nutrition and Lead Poisoning Training. Therefore, a provisional license for 90 days will be issued, which will expire on 10/28/2023.

In the event additional requirements are needed, the applicant will be notified. A license will be issued once all requirements are met.

Appeal rights were provided, and an Exit Interview was conducted with applicant Masoumeh Mahdipour Shamloo.

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, its tools, and methods, please visit the Program Website
at https://www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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