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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624033
Report Date: 07/30/2021
Date Signed: 07/30/2021 12:12:46 PM

Document Has Been Signed on 07/30/2021 12:12 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:NAZARI, NASEMEHFACILITY NUMBER:
343624033
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/30/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nasemeh NazariTIME COMPLETED:
12:30 PM
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On July 30th, 2021 at 11:00 AM, Licensing Program Analyst (LPA) Tanya Washington met with Applicant Nasemeh Nazari for an announced change of location/ pre-licensing inspection. Applicant's previous license number is #343621533. The visit was translated by Applicant's daughter from Farsi/ Dari to English. Applicant plans to operate 7 days a week, 24 hours a day.

LPA and Applicant toured the single story, 5 bedroom and 2 bathroom home. Applicant stated that they are the owners of the home, LPA is pending receipt of control of property. Applicant stated that she does not plan to purchase liability insurance for her business. LPA explained that if a policy is not purchased in the amount of $300,000 than an affidavit form LIC282 is required to be used.

Applicant plans to utilize two main rooms (living room and dining room) which are located upon entry to the home and two bedrooms and bathroom on the left side of the home upon entry. Applicant's other three bedrooms, bathroom on the right side passed the kitchen area and shed in the backyard, partially converted garage will be off limits to children in care.
Applicant understands that children may never enter the off-limit areas of the home. Applicant acknowledges she is required to notify licensing prior to making changes to off-limit areas so that they may be inspected for safety.

LPA observed a carbon monoxide detector a functional smoke detector and a 2A10BC fire extinguisher. Hazardous cleaning products, knives, and medications are all stored inaccessible to children. Applicant understands that poisons must be locked.

Continued on LIC809C
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2021
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: NAZARI, NASEMEH
FACILITY NUMBER: 343624033
VISIT DATE: 07/30/2021
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Applicant plans to utilize her backyard for outdoor play, she understands that 100% supervision must be maintained at all times when children are around bodies of water or in unfenced areas. Applicant was recommended to obtain permission from parents in writing in order to be able to take children on trips outside of the facility. Applicant stated there are no firearms in the home. There is no fireplace in the home and no bodies of water.

Applicant has completed the required EMSA certified CPR and First Aid class which is valid until 01/23/23. Due to Applicant's relocation she is required to sign up and complete Preventative Health and Safety course which includes an hour of nutrition training and Lead Exposure.
Proof of AB1207 mandated reporter training is not applicable to the Applicant as she has limited English proficiency. LPA explained that the OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/.

LPA discussed current COVID-19 guidelines, postings, and protocols. LPA discussed Type A and Type B citations, Zero Tolerance, and Civil Penalties. LPA discussed open door policy, supervision, fire drills, children’s personal rights, reporting requirements, and the smoking prohibition with the applicant. A current roster of children enrolled must be available and maintained for a period of three years, even after children are no longer in care.

Annual fees must be paid promptly and by the due date or late fees will be assessed. Applicant understands that the license is non-transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

Continued on LIC809C

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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: NAZARI, NASEMEH
FACILITY NUMBER: 343624033
VISIT DATE: 07/30/2021
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LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the applicant can request to be added to the distribution list to receive Quarterly Updates. LPA provided form LIC311D and discussed the required forms for children's records, employee records, and forms required to be kept on file at the facility. LPA provided the Licensing Agency website (WWW.CCLD.CA.GOV), so that the applicant may obtain updated licensing information, regulations, PINs, and forms.


-Prior to licensure Applicant is required to comply with the following:

- Submit control of property
- LIC508 Criminal Record Statements for all adults living in the home
- Proof of enrollment for Preventative Health and Safety class which includes nutrition and Lead Exposure training
- Submit current Tuberculosis clearance for Elaheh Rezaei
- Fingerprint clearance for Elaheh Rezaei
- put up required licensing forms (provided during inspection)
- lock paint and other items hazardous to children outside in the backyard
- Remove a pile of brick from the yard
- Put away metal bed frames leaning against shed in the backyard

Applicant stated that all items will be complete by August 16th, 2021. LPA will return for a follow up inspection
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC809 (FAS) - (06/04)
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