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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500480
Report Date: 12/09/2021
Date Signed: 12/09/2021 11:44:31 AM

Document Has Been Signed on 12/09/2021 11:44 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:ALIZADEH, FERESHTEHFACILITY NUMBER:
344500480
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Fereshteh AlizadehTIME COMPLETED:
12:00 PM
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On 12/09/2021 at 10:00 AM Licensing Program Analyst (LPA) Jeevun Birk-Miller conducted a pre-licensing inspection and met with applicant, Fereshteh Alizadeh and Mohammad Ahmadzai who provided assistance during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. The 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.

A health and safety inspection was conducted inside and out. The two story home has five bedrooms, three bathrooms, a living room, formal living/dinning room, daycare area, kitchen/dinning area, shed, garage, and fenced backyard. The off-limit areas in the home are: entire upstairs, downstair bedroom, garage, and shed. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. The applicant acknowledges that she must contact LPA prior to making an off-limits area on-limits and vice versa. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detectors were observed in the home. LPA observed a 2-A-10-BC fire extinguisher. Safety latches are in use on some kitchen drawers and bathroom cabinet. The applicant understands that she must ensure the safety latches are not broken. The fireplace in the home is appropriately barricaded to prevent access by children and outdoor play space is fenced.

Preventative health and current pediatric CPR and first aid training was verified and CPR expires 04/24/2023. Mandated Reporter Training certificate was observed and expires 10/21/2023. There are no bodies of water on the premises. The applicant stated there are no fire arms in the home. Applicant was encouraged to maintain supervision at all times. LPA provided information about Type A/B citations and civil penalties. Report continued on 809-C...
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Jeevun Birk
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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: ALIZADEH, FERESHTEH
FACILITY NUMBER: 344500480
VISIT DATE: 12/09/2021
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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 .

This facility evaluation report was reviewed and discussed with the applicant. LIC 311D, records, postings, and reporting requirements were discussed. LPA discussed supervision, personal rights, criminal record clearances, staffing ratios and capacity, and maintaining buildings and grounds. Applicant was encouraged to visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

Effective today, 12/09/2021, this home is licensed 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 Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

An exit interview was conducted. A copy of this report was given to the Applicant to keep on file at the facility.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Jeevun Birk
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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