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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619058
Report Date: 06/24/2024
Date Signed: 06/25/2024 09:38:48 AM

Document Has Been Signed on 06/25/2024 09:38 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:ASHRAFI, MITRAFACILITY NUMBER:
343619058
ADMINISTRATOR/
DIRECTOR:		ASHRAFI, MITRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 483-0641
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
06/24/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Mitra AshrafiTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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On Monday, June 24, 2024 at 10:30 PM, Licensing Program Analyst (LPA) Tanya Washington met with Licensee, Mitra Ashrafi, for the purpose of an unannounced annual/random inspection. Upon arrival LPA observed Licensee providing care and supervision to six day care children ages; 1, 2, 3, 3, 3, and 6. All individuals subject to criminal background review have obtained a criminal record clearance. Facility hours of operation are Monday through Friday from 7:30 AM to 5:30 PM.

A health and safety evaluation was conducted in all areas accessible to children. Off-limit areas include: all three bedrooms, backyard, living room and dining room. Licensee acknowledged that children may never enter these off-limit areas. LPA observed that the facility is clean, safe, sanitary, and in good repair. Licensee utilizes the playroom with attached bathroom and the front yard for outdoor play LPA observed a functioning smoke detector, carbon monoxide detector, and a full 2A10BC fire extinguisher. The facility has adequate toys that appear to be safe for children to use. The licensee stated there are no weapons or poisons in the home. The fireplace located in the home is inaccessible to children and is located in the off limit area of the home. There are no bodies of water on the premises of the facility.

LPA reviewed four children’s files which were observed to be complete. Required postings and the children’s roster were observed. LPA observed that the last fire drill was documented 06/03/2024. Licensee’s CPR/First Aid card expires 01/2026. Licensee's Mandated Reporter certification is valid until 04/17/2025.. LPA reviewed safe sleep checks for infants under two years old.

LPA verified that the annual fees are current. Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

PAGE 1. REPORT CONTINUES ON LIC809-C
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2024
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 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: ASHRAFI, MITRA
FACILITY NUMBER: 343619058
VISIT DATE: 06/24/2024
NARRATIVE
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LPA discussed the safe sleep regulations with licensee 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. LPA also informed licensee 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.

Licensee understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the day. Licensee understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report/LIC 624 shall be submitted within 7 days to remain in compliance. Licensee understands that if any structural changes are made to the home; licensing must be notified PRIOR to construction. Licensee understands that if she wants to make any changes to OFF-limit areas to an ON-limit area, she must notify licensing and LPA must do an inspection BEFORE children are allowed in said area. Licensee understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to 3 years.

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: https://www.ada.gov/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Page 2. REPORT CONTINUES ON LIC809C
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ASHRAFI, MITRA
FACILITY NUMBER: 343619058
VISIT DATE: 06/24/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

A notice of site visit was given and must remain posted for 30 days. No Title 22 deficiencies are cited based on today's inspection. Exit interview conducted and report was reviewed with the licensee Mitra Ashrafi. During the exit interview, the Licensee Mitra Ashrafi, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC809 (FAS) - (06/04)
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