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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624365
Report Date: 06/16/2023
Date Signed: 06/16/2023 01:58:47 PM

Document Has Been Signed on 06/16/2023 01:58 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MANSORI, KARIMAFACILITY NUMBER:
343624365
ADMINISTRATOR:MANSORI, KARIMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 849-9591
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Karima MansoriTIME COMPLETED:
02:15 PM
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At 1:00 p.m. on Friday, June 16th, 2023, Licensing Program Analyst (LPA) Karyn Guerra met with Licensee, Karima Mansori, for the purpose of an unannounced, required - 1 year inspection. LPA observed a census of 7 children including 3 preschoolers, 3 school agers, and 1 infant child over one year supervised by Licensee and spouse assistant. Facility hours of operation are from 8:00 a.m. - 11:59 p.m., Monday thru Friday. Off limits areas include all bedrooms, bathroom 2, living room, and garage. Licensee requested during inspection to designate the kitchen as off limits. Licensee understands that child care children shall not enter these off limits areas of the home. There is a second outdoor entry to access the on limits child care areas of the home.

All individuals subject to criminal background review have obtained a criminal record clearance. Licensee 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.

A health and safety inspection was conducted in all areas accessible to children. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated that there are no weapons nor poisons in the home. Toxic and hazardous items were appropriately stored, inaccessible to children. Fireplace in the home is in an off limits areas. Doors leading into the living room remain closed to prevent access.

LPA reviewed staff and children's files and observed current in person EMSA CPR and First Aid certification, expiring January 2024. Fire drills have been conducted and

report continued on 809-C.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MANSORI, KARIMA
FACILITY NUMBER: 343624365
VISIT DATE: 06/16/2023
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documented. A facility roster was observed. LPA observed immunization records, emergency identification, signed parents rights, and consent for emergency medical treatment in children's files. LPA reminded Licensee about affidavit forms regarding liability insurance. LPA informed Licensee of recent regional office relocation and provided updated parent's rights form and poster.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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.

This provider is not currently providing Incidental Medical Services IMS services to children in care. 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: https://www.ada.gov/childqanda.htm.

Exit interview conducted and report was reviewed with the licensee, Karima Mansori. A Notice of Site Visit was given and must remain posted for 30 days. To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.

In the areas that were evaluated, no deficiencies were cited during inspection.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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