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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624523
Report Date: 10/11/2022
Date Signed: 10/11/2022 10:52:25 AM

Document Has Been Signed on 10/11/2022 10:52 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:MEHDIZADE, KHADIJAFACILITY NUMBER:
343624523
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
10/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Khadija MehdizadeTIME COMPLETED:
11:15 AM
NARRATIVE
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On Tuesday, October 11, 2022 at 9:00 AM, Licensing Program Analysts (LPAs) Mandie Goodwin and Amanda Sutter met with Applicant Khadija Mehdizade and for the purpose of an announced pre-licensing inspection. During today’s visit, applicant’s husband was also present in the home. Applicant speaks Farsi. All individuals subject to criminal background review have obtained a criminal record clearance. Applicant plans to operate Monday through Friday from 8:30 AM to 7:00 PM.

A health and safety inspection was conducted inside and outside the home. The home is a one story duplex and includes 2 bedrooms, 1 bathroom, kitchen, a living room, a garage, and a fenced outdoor area. Off-limit areas will include: master bedroom, and garage. Applicant understands that children may never enter these off-limit areas.

Toxic and hazardous items are inaccessible to children and out of children’s reach. LPAs advised the applicant that if there are ever any poisons at the home, all poisons must be locked with a key lock or combination lock. Sharp knives and medication are stored above the refrigerator out of children’s reach. A functioning smoke detector, carbon monoxide detector, and 2A10BC fire extinguisher were observed. Applicant stated that there are no weapons in the home.

Applicant has completed the required Preventative Health and Safety course with the Lead Poisoning Prevention training. Current EMSA approved pediatric CPR/First Aid trainings were verified and expire 6/12/24. Applicant is exempt from Mandated Reporter training due to it not being provided in their first language.

Applicant was encouraged to maintain supervision at all times. Applicant 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. LPA discussed Type A/B citations, open door policy, fire drills, children’s personal rights 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. Report continues on page 2...

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MEHDIZADE, KHADIJA
FACILITY NUMBER: 343624523
VISIT DATE: 10/11/2022
NARRATIVE
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LPAs explained to applicant that if they relocate and wants to continue to provide care, they must submit a change of location application and have the new home inspected. Applicant understands that if any structural changes are made to the home, licensing must be notified prior to construction. Applicant understands that if they want to make any off-limit area an on-limits area, licensing must be notified and LPAs must do an inspection before children are allowed in the area. Applicant understand that licenses are not transferable, and once licensed, licensees must live in the home and be present for 80% of the operating hours. LPAs reviewed with applicants the LIC 311D (Forms/Records To Keep In Your Family Child Care Homes), children’s forms/records, facility forms/records, and information to be posted.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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: http://www.ada.gov/childqanda.htm

Report continues on page 3...
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MEHDIZADE, KHADIJA
FACILITY NUMBER: 343624523
VISIT DATE: 10/11/2022
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LPAs discussed the safe sleep regulations with Applicant 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. LPAs also informed Director 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the applicant Khadija Mehdizade.

As of today 10/11/2022, facility is approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2. Landlord consent required for 7th and 8th child.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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