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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624640
Report Date: 12/29/2022
Date Signed: 12/29/2022 03:31:22 PM

Document Has Been Signed on 12/29/2022 03:31 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:AZIZI, BIBI MOZHGANFACILITY NUMBER:
343624640
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/29/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Bibi Mozhgan AziziTIME COMPLETED:
03:40 PM
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On Thursday December 29, 2022, at approximately 2:20 PM, Licensing Program Analysts (LPA) Josiah Gathing met with Applicant Bibi Mozhgan Azizi for the purpose of an announced pre-licensing inspection. Applicant plans to operate Monday – Friday from 7:00 PM to 6:00 PM. Applicant’s husband and five minor children were also present during today’s inspection. All persons subject to criminal record background review have been cleared. Applicant’s first language is Dari, and her child provided translation during today’s inspection.

A health and safety inspection was conducted inside and outside the home. The single- story home has three bedrooms, one bathroom, living room, and kitchen, garage, and back yard. Off-limits areas: Bedroom #2, Bedroom #3, Kitchen, Garage, and Backyard.



Sharp knives and medications are stored in kitchen cabinets out of children’s reach. LPA observed a functioning smoke detector, full 2A10BC fire extinguisher, and first aid kit in the home. There was no carbon monoxide detector in the home during today’s inspection. Per applicant, there are no weapons or poisons in the home.

Applicant completed the required Preventative Health and Safety course with the Lead Poisoning Prevention training on December 4, 2021. Applicant’s EMSA certified CPR and First Aid Certificate expires October 9, 2023. Mandated Reporter Training is not offered in applicant’s first language, therefore she is exempt from the training. Required documents were not posted during today’s inspection.

Applicant was encouraged to maintain supervision at all times in unfenced areas. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed.

Report continues on LIC809-C…

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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: AZIZI, BIBI MOZHGAN
FACILITY NUMBER: 343624640
VISIT DATE: 12/29/2022
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Applicant 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.

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 submitting 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



LPA 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. LPA also informed Applicant 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.

An exit interview was conducted with Applicant and Covid-19 protocols were discussed. LIC311D, records, postings, and reporting requirements were discussed. LPA discussed personal rights, criminal record clearances, ratios and capacity, and maintaining buildings and grounds. Applicant was encouraged to visit the Department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

Prior to receiving a license, the applicant must provide the following to the LPA:

1. Functioning carbon monoxide detector in the home.

2. Required documents posted in the home.

Copy of this report was reviewed and provided to applicant. This report will be kept in the facility file and will be made available for public review upon request.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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