<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624640
Report Date: 12/22/2023
Date Signed: 12/28/2023 11:30:26 AM

Document Has Been Signed on 12/28/2023 11:30 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AZIZI, BIBI MOZHGANFACILITY NUMBER:
343624640
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
12/22/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Bibi Mozhgan AziziTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Kyrsten Williams and Stephanie Piring met with Applicant Bibi Mozhgan Azizi for the purpose of an unannounced annual inspection. Applicant plans to operate Monday – Friday from 7:00 AM to 6:00 PM. Applicant’s three minor children and adult son were also present during today’s inspection. Applicant’s first language is Dari, and her child provided translation during today’s inspection.

LPA conducted a health and safety inspection and observed that the facility is clean, safe, sanitary, and in good repair with ventilation. LPA observed the required documents were posted where visible to parents. LPA observed that there were no hazardous items—such as cleaning compounds, medications, or sharp objects—accessible to children. The fire extinguisher appeared to be in working condition and accessible. LPA observed the smoke and carbon monoxide detectors are functioning. The facility has equipment and toys safe for children. During inspection, licensee requested LPA inspect the backyard to change it from an off limit area to an on limit area. The backyard is safe and is fenced. Licensee acknowledged that in areas that are not fenced, 100% supervision is required. Off-limit areas now include bedroom #2, bedroom #3, and garage. Licensee acknowledged that childcare children may never enter off-limit areas. The licensee stated there are no weapons on the premises. LPA did not observe any bodies of water on the premises.

LPA did not observe a current children's roster or fire drill log. Licensee stated she completed a fire drill last week, however, did not document it. LPA reviewed children’s files and observed that most of the required documentation was present in each child's file. One infant is missing immunization records. LPA observed the CPR/First Aid certificate was current. Licensee is exempt from completing Mandated Reporter Training due to it not being available in her primary language. LPA reviewed staff and facility files and observed the required documentation.

The licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
pg 1. report continues on LIC809-C
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Kyrsten Williams
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2023
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
Document Has Been Signed on 12/28/2023 11:30 AM - It Cannot Be Edited


Created By: Kyrsten Williams On 12/22/2023 at 01:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AZIZI, BIBI MOZHGAN
FACILITY NUMBER: 343624640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.841
Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in no facility roster was completed and available, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2024
Plan of Correction
1
2
3
4
Licensee completed facility roster during inspection and provided proof to LPA.
Type B
Section Cited
CCR
102418(a)
102418 Immunizations (a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 4 children enrolled do not have immunization record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
1
2
3
4
Licensee will obtain a copy of completed immunization record and/or scheduled appointments for the child. Licensee will submit photo verification to LPA via text or email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Seychelle De Luca
LICENSING EVALUATOR NAME:Kyrsten Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023


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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AZIZI, BIBI MOZHGAN
FACILITY NUMBER: 343624640
VISIT DATE: 12/22/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA discussed the safe sleep regulations with the licensee 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 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.

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: https://www.ada.gov/resources/child-care-centers/.

The licensee was informed of the www.MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Exit interview conducted and report was reviewed with the licensee, Bibi Mozhgan. A notice of site visit was given and must remain posted for 30 days.

Deficiencies are cited on the subsequent page of this report (LIC809-D) under the California Code of Regulations, Title 22. The licensee was provided a copy of their Appeal Rights (LIC9058) and the licensee's signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Kyrsten Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3