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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624032
Report Date: 08/12/2021
Date Signed: 08/12/2021 10:09:09 AM

Document Has Been Signed on 08/12/2021 10:09 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:NURISTANI, ARZOOFACILITY NUMBER:
343624032
ADMINISTRATOR:NURISTANI, ARZOOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 627-9345
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/12/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nuristani, ArzooTIME COMPLETED:
10:30 AM
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On Thursday, August 12 2021, at approximately 9:00 AM, Licensing Program Analyst (LPA) Alize Tillery met with Applicant Arzoo Nuristani for the purpose of conducting an announced change of location and increase in capacity, pre-licensing inspection. During today's inspection, applicant and her two school age children were present in the home. Applicant and all other adults (husband) have criminal record clearances on file. Applicant plans to operate Monday - Friday from 7:30 AM to 9:30PM. Applicant submitted proof of control of property.

A health and safety inspection was conducted inside and out of the home. The one-story facility includes 3 bedrooms, 2 bathrooms, kitchen/dining room area, living room, fenced front yard and fenced backyard. The Off-limits areas include the master bedroom and bathroom, the laundry room and backyard area. Licensee acknowledged that children may never enter these off-limit areas.



There is not a fireplace in the home. Toxic and hazardous items are inaccessible to children and out of children's reach. Sharp knives are stored in the kitchen out of children's reach. Applicant will have medications stored above the refrigerator, out of children’s reach. A first aid kit, a functioning smoke detector, carbon monoxide detector and a full 2A10BC fire extinguisher were observed in the home. LPA observed all required licensing postings along with COVID19 posters.

Report continues on LIC809-C.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: NURISTANI, ARZOO
FACILITY NUMBER: 343624032
VISIT DATE: 08/12/2021
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LPA discussed Unusual Incident Report requirements with applicant. Applicant completed the required Preventative Health and Safety course on 07/05/2020. Applicant has a current EMSA certified CPR and First Aid card which expires 06/21/2022. Applicant is aware the Mandated Reporter Training is to be taken every two years. Applicant stated there are no weapons in the home and there are no bodies of water on the premises. Applicant understands that prior to making alterations or additions to the home or grounds, he/she shall notify the Department of the proposed changes.

Applicant was encouraged to visit the Department’s website at www.cdss.ca.gov for more information regarding child care updates, forms, regulations and legislation. This report and a Notice of Site Visit was provided to Licensee. Licensee acknowledges the Notice of Site Visit must be posted for 30 days.



As of today, August 12, 2021, facility is approved for a Large Family Child Care Home license for a maximum capacity (when there is an assistant present): 12 – no more than 4 infants. Capacity of 14 – no more that 3 infants, 1 child in kindergarten or elementary school and 1 child at least age 6.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC809 (FAS) - (06/04)
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