313625075-7-7-2023-03-CC-KOWS-CTHN2W-20230707100525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313625075
Report Date: 07/07/2023
Date Signed: 07/07/2023 10:05:32 AM

Document Has Been Signed on 07/07/2023 10:05 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	NORI, KOUBRA		FACILITY NUMBER:	313625075
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	07/07/2023
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Koubra Nori and xxxxx		TIME COMPLETED:	10:30 AM

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	Licensing Program Analysts (LPA's) Owens and Vang met with applicant for a Change of location inspection. Applicant's first language is Farsi/Dari, and her adult daughter translated the entire inspection. Present at time of inspection were one adult daughter, three minor children and husband. LPA toured the home inside and out. LPA explained about obtaining $300,000 liability insurance. She understands that until a policy is obtained, she must use the affidavit. Applicant has certificates of completion for 15 hours of health and safety training including CPR and First Aid with expiration date of 1/2024. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Applicant, Koubra Nori, 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. LPA has provided the Applicant with the web site to enable access to all updated forms, requirements and changes. Applicant understands that she needs to notify licensing for any modification inside and out of the home. Off-limit areas include: Three bedrooms, Laundry room and Garage. Applicant understands that children may never enter these off-limit areas. LPA reviewed the fire drill requirements. Applicant stated there are no weapons in the home. Fire extinguisher, carbon monoxide detector and smoke detectors meet regulation. Hazardous cleaning compounds are inaccessible to children. Sharp utensils and Medications are inaccessible to children. Continued on next page.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Katrina Owens
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NORI, KOUBRA	FACILITY NUMBER: 313625075
	VISIT DATE: 07/07/2023

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
26
27
28
29
30
31
32

The backyard is fenced and there are no bodies of water. Applicant understands that 100% supervision is required in any unfenced areas. There is no pool at the home. There are no pets at the home. There are no stairs at the home. Planned hours of operation are Monday through Sunday, 7:30 am to 11 pm and other hours as arranged.

LPA observed proof that applicant have met the requirements of SB 792.

Proof of AB1207 mandated reporter training is not applicable to as Applicant has limited English proficiency. LPAs explained that the OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/.

LPA discussed the safe sleep regulations with licensee and her daughter and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed 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.

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

LPA provided the Community Care Licensing website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current in regards to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws childcareadvocatesprogram@dss.ca.gov.

LPA discussed with licensee 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. Continued on next page

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Katrina Owens
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NORI, KOUBRA	FACILITY NUMBER: 313625075
	VISIT DATE: 07/07/2023

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
26
27
28
29
30
31
32

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 licensed- 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 receive email communication.

Effective today 7/7/2023, applicant is license to serve up to either 8 children, two (2) of which must be at least 6 years of age and no more than two (2) may be infants; or 6 children, three (3) of which may be infants; or 4 infants only. Infants are children under the age of 2 years.

Exit Interview were conducted.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Katrina Owens
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3