<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845544
Report Date: 03/07/2024
Date Signed: 03/11/2024 12:39:10 PM

Document Has Been Signed on 03/11/2024 12:39 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:GHOLIPOOR FAMILY CHILD CAREFACILITY NUMBER:
334845544
ADMINISTRATOR:GHOLIPOOR,MEHRNAZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 506-1915
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
03/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:46 PM
MET WITH:Mehrnaz "Mary" GholipoorTIME COMPLETED:
06:16 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 March 7, 2024, at 2:48 PM, Licensing Program Analyst (LPA) Anastasia Flores, arrived for the purpose of a case management visit due to licensee’s probationary status. Upon arrival LPA observed ten children in care (one infant and 9 children between the ages of 2 to seven years old). Licensee had the infant on the bed in the office sleeping upon LPA’s arrival. LPA toured the facility inside and out, took photos of deficiencies.

Due to incomplete staff records and deficiencies found in the home, the licensee is being cited for the following deficiencies. Title 22 violation:102416.5 (e) Staffing Ratio and Capacity, 102425 (a) Infant Safe Sleep, 102417(g)(4) Operation of a Family Child Care Home, 102417(g)(10) Operation of a Family Child Care Home, Health and Safety code: 1596.8662(b)(1) Administration of Child Day Care Licensing,1597.622(a)(1) Administration of Child Day Care Licensing, 1597.622(c) Administration of Child Day Care Licensing. See 809D's for deficiencies.

An exit interview was conducted, and a copy of this report, 809D's, appeal rights, along with a notice of Site Visit was handed to licensee, Mehrnaz (Mary)Gholipoor.

Licensee understands it must be posted in a prominent location for the next 30 days.

Due to FAS error, this a duplicate of report handed to licensee on 03/07/24. Original signature on reports are are filed in the facility file.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Anastasia Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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 5
Document Has Been Signed on 03/11/2024 12:39 PM - It Cannot Be Edited


Created By: Anastasia Flores On 03/11/2024 at 08:34 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GHOLIPOOR FAMILY CHILD CARE
FACILITY NUMBER: 334845544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2024
Section Cited
CCR
102416.5(e)

1
2
3
4
5
6
7
102416.5 (e) Staffing Ratio and Capacity If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). icensee will email a written statement of agreeing and understanding to Regulation 102416.5 Staffing Ratio and Capacity. Licensee will also submit a written plan to LPA, stating how this regulation will be followed and provide a schedule of staff shifts maintaining proper capacity and ratios. This was not met as evidenced by...

1
2
3
4
5
6
7
Licensee informed LPA that her assistant (S2) was supposed to arrive at 2pm but the assistants car broke down. Licensee called another assistant upon LPA arrival and at 3:05 PM, S3 arrived to assist with the children in care. Licensee will provide a statement to LPA Flores via email explaining how she will stay in capacity and staff schedule by 3/11/24.
8
9
10
11
12
13
14
Based on LPA observation and interview with licensee at 2:48PM, licensee was alone with ten children one of them an infant. This poses a potential health, safety and personal rights risk to children in care.
8
9
10
11
12
13
14
Type B
03/11/2024
Section Cited
CCR102425(a)

1
2
3
4
5
6
7
102425 (a) INFANT SAFE SLEEP there shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.This was not met as evidenced by...
1
2
3
4
5
6
7
Licensee will provide to LPA Flores via email, how she will remain in compliance with infant safe sleep, and where the infants 12 months and younger will sleep by 3/11/24.
8
9
10
11
12
13
14
Based on interview with licensee, one infant (C10) was placed on the bed to sleep while licensee was conducting office work. LPA arrived and licensee came out of the bedroom with C10 in her arms. This poses a potential health, safety and personal rights risk to children in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Pauline Beschorner
LICENSING EVALUATOR NAME:Anastasia Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/11/2024 12:39 PM - It Cannot Be Edited


Created By: Anastasia Flores On 03/11/2024 at 08:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GHOLIPOOR FAMILY CHILD CARE
FACILITY NUMBER: 334845544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2024
Section Cited
CCR
102417(g)(4)

1
2
3
4
5
6
7
102417(g)(4) Operation of a Family Child Care Home: The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.This was not met as evidenced by...
1
2
3
4
5
6
7
Licensee will fix the child safety locks that were broken in the bathroom and provide evidence to LPA Flores via email by 3/14/24. Licensee will remove all items that are hazardous to children until safety locks are corrected.
8
9
10
11
12
13
14
Based on LPA Flores observation (photos taken) the bathroom utilized by children in care had mouthwash, toothpaste and the medicine cabinet had personal hygiene items that are easily accessible to children in care. This poses a potential health, safety and personal rights risk to children in care.
8
9
10
11
12
13
14
Type B
03/11/2024
Section Cited
CCR102417(g)(10)

1
2
3
4
5
6
7
102417(g)(10)Operation of a Family Child Care Home: The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to. A baby walker shall not be allowed on the premises of a family childcare home in accordance with Health and Safety Code Section 1596.846(b) and (c).This was not met as evidenced by...
1
2
3
4
5
6
7
Licensee removed the bouncer/walker 3/07/24 stated she will not use the item again in the future.
8
9
10
11
12
13
14
Based on LPA observation (photo taken),Licensee had baby bouncer/walker in the day care at the time of inspection. This poses a potential health, safety and personal rights risk to children in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Pauline Beschorner
LICENSING EVALUATOR NAME:Anastasia Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/11/2024 12:39 PM - It Cannot Be Edited


Created By: Anastasia Flores On 03/11/2024 at 09:10 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GHOLIPOOR FAMILY CHILD CARE
FACILITY NUMBER: 334845544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2024
Section Cited
HSC
1596.8662(b)(1)

1
2
3
4
5
6
7
1596.8662(b)(1) 1596.8662(b)(1) Administration of Child Day Care Licensing On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This was not met as evidenced by...
1
2
3
4
5
6
7
Licensee will obtain certificates from staff missing Mandated Reporter and send to LPA Flores via email by 3/28/24.
8
9
10
11
12
13
14
Based on interview and record review the licensee did not comply with the section cited above in three out of four staff files reviewed do not have current mandated reporter certificate at time of inspection, which poses a potential health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
03/28/2024
Section Cited
HSC1597.622(a)(1)

1
2
3
4
5
6
7
1597.622(a)(1) Administration of Child Day Care Licensing 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will obtain immunization records from staff and send to LPA Flores via email by 3/28/24.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the section cited above in four out of four staff files reviewed, immunizations were not present, Which poses a potential health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Pauline Beschorner
LICENSING EVALUATOR NAME:Anastasia Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/11/2024 12:39 PM - It Cannot Be Edited


Created By: Anastasia Flores On 03/11/2024 at 09:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GHOLIPOOR FAMILY CHILD CARE
FACILITY NUMBER: 334845544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2024
Section Cited
HSC
1597.622(c)

1
2
3
4
5
6
7
1597.622(c) Administration of Child Day Care Licensing The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will obtain TB records from staff#1, 2, and 4 and send to LPA Flores via email by 3/28/24.
8
9
10
11
12
13
14
Based on interview & record review, the licensee did not comply with this section cited above in three out of four staff do not have TB records on file at time of inspection, which poses a potential health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Pauline Beschorner
LICENSING EVALUATOR NAME:Anastasia Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5