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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100913
Report Date: 01/28/2022
Date Signed: 01/28/2022 11:29:19 AM

Document Has Been Signed on 01/28/2022 11:29 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:GHOLAMI, ZAHRA FAMILY CHILD CAREFACILITY NUMBER:
376100913
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
01/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Zahra GholamiTIME COMPLETED:
11:50 AM
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On 1/28/22 at 9:27am, Licensing Program Analyst (LPA) Patrick Ma conducted an announced Pre-Licensing Change of Location inspection with Licensee Zahra Gholami. Also present in the home were Licensee's relatives, Mohammad Ashur, Wahida Ayoubi, and Husua Ayoubi. The 3 bedroom, 1 bathroom, 1 story home was toured and inspected to ensure an environment safe for the care and supervision of children.

Applicant will be using the family room, dining room, bathroom, and kitchen for child care. Off limit areas are all 3 bedrooms, garage, and backyard. The applicant has sufficient toys and equipment available. Licensee will use a local park for outdoor activities. Licensee was advised to provide visual supervision at all times when children are outdoors.

The fire extinguisher, carbon monoxide detector, and smoke detector meet requirements and are operational. There are no bodies of water on the property. Applicant states that there are no weapons in the home. Licensee states that they have sufficient financial resources to sustain the license. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Licensee owns the home and has provided proof of control of property and the Landlord Notification. Applicant understands that, at this time, she may care for up to 8 children. First Aid and CPR expire on 3/2022 and preventative health practices course was completed on 3/11/18 and the Lead Poisoning Prevention training on 11/11/21. Applicant completed Mandated Reporter Training and expires on 11/4/23. Staff immunization requirements per SB792 were met. Licensee was reminded that annual fees are due on the date they were licensee every year.
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GHOLAMI, ZAHRA FAMILY CHILD CARE
FACILITY NUMBER: 376100913
VISIT DATE: 01/28/2022
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The new provider packet was reviewed with the Licensee including information on ratios and capacity, child abuse reporting, children’s records, immunizations, adults living or working in the home, car seat law, shaken baby syndrome, SIDS, effects of lead poisoning, COVID safety guidance, and the YMCA Resource Center. Applicant was reminded that corporal punishment, smoking, walkers, exersaucers, jumpers, and bouncy seats are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA discussed the safe sleep regulations with 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.

Licensee 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.

LPA discussed and provided applicant with the following information:
• Child Care Advocates - email address childcareadvocatesprogram@dss.ca.gov.
• For common questions or questions regarding licensing requirements to contact the Child Care Licensing duty line at 619-767-2248.
• To report COVID-19 cases contact the Health & Human Services Agency Epidemiology Department at 619-692-8636.
• If a child, staff, or facility contact has tested positive for COVID-19, please notify the County of San Diego by filling out the COVID-19 Online Notification Form:
https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/community_epidemiology/dc/2019-nCoV/COVID-19_Notification_Form.html
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GHOLAMI, ZAHRA FAMILY CHILD CARE
FACILITY NUMBER: 376100913
VISIT DATE: 01/28/2022
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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

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.

The following corrections are needed:
• Hazardous items in the bathroom need to be latched/locked and secured out of reach of children
• Fireplace need to be covered
• Water heater needs to be made inaccessible
• Off-limit rooms and backyard need to be made inaccessible

Applicant understands that corrections must be submitted to the Department within 30 days or the application may be denied.

Exit interview conducted and report was reviewed with the Licensee Zahra Gholami. Appeal Rights (LIC9058) was given along with the report (LIC809) to the Licensee.
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
LIC809 (FAS) - (06/04)
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