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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100913
Report Date: 01/16/2024
Date Signed: 01/16/2024 04:46:45 PM

Document Has Been Signed on 01/16/2024 04:46 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, 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: 8CENSUS: 3DATE:
01/16/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Zahra GholamiTIME COMPLETED:
05:05 PM
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On January 16, 2024 at 1:15 p.m. Licensing Program Analyst (LPA), Leilani Curtis conducted an unannounced Annual Inspection and met with Licensee, Zahra Gholami. Also present was Mohammad Ashur, Husna Ayoubi, Wahida Ayoubi and Asiya Ayoubi. (aka Salda Ayoubi) does not have a criminal record clearance and is not associated to the facility. The licensee states that Asiya Ayoubi has lived at the facility since licensure, 3/8/2022. LPA provided the LIC 126, Entrance Checklist to Licensee. Two school age daycare children arrived at approximately 3:13 p.m. A third daycare child arrived at approximately 4:00 p.m. The facility was observed operation within ratio and capacity. LPA conducted a tour of the home inside and outside per facility sketch. Licensee is using the following areas for daycare: living room, family room, dining area, kitchen and hallway bathroom. Off-limits areas include: bedroom #1, bedroom #2, bedroom #3, bathroom #2 (located within bedroom #1), rear yard and garage.

Licensee has provided adequate space for the children to eat, sleep and play within the home. Home is clean, orderly and has adequate ventilation. Children’s toys and play equipment are available and observed free of hazards. There are no stairs in the home. There is a working telephone/email address. All cleaning compounds, detergents, medications, and poisons are made inaccessible through latches, locks, and/or placed up on high surfaces. The fireplace is screened. The fire extinguisher and smoke and carbon monoxide detector are operational. Licensee states there are NO firearms or other weapons in the home. There are no existing bodies of water present. The licensee states that she utilizes a nearby park for outdoor activities. The licensee understands that she must maintain 100% supervision of the children in care while at the park. Children records were reviewed for Emergency Information. The licensee does not maintain Notification of Parents’ Rights forms (LIC995A) in the five files reviewed. The licensee does not maintain 15 minute sleep documentation for the three infant files reviewed or Individual Infant Sleep Plans (LIC9227) for the two infants under 12 months whose files were reviewed.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 01/16/2024
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 Pediatric CPR and First-Aid certificates are valid through 03/2024. The licensee’s mandated reporter certification expired on 11/4/23. LPA advised Licensee that all personnel that interact/provide care and supervision to children must have proof of training or renewal training on site to review. Training can be taken at: www.mandatedreporterca.com. Immunization records per SB792 were reviewed and are in compliance.

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/.



LPA reviewed the following with Licensee: Recently Approved Safe Sleep Regulations PIN 20-24-CCP dated 9/15/20, supervision, criminal record clearances. Licensee is reminded that corporal punishment, smoking, walkers, exersaucers, jumpers and bouncy seats shall never be permitted during daycare operation. Licensee is aware that interference with a child’s daily functions, corporal punishment, physical and mental abuse is not allowed. Licensee is reminded to make anything that reads, "Keep Out of Reach of Children" inaccessible to children.

See LIC809D for cited deficiencies. A civil penalty has been assessed.

LPA Curtis informed licensee that this report dated 1/16/24 documents one Type A citation. Type A citations shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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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: 01/16/2024
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Also, LPA Curtis informed the licensee to provide a copy of this licensing report dated 1/16/24 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Please be advised that FAILURE TO PAY the required civil penalty payment may result in in the REVOCATION OF YOUR LICENSE. You must respond within 30 days with the payment of or a proposed payment plan that includes the first payment. Further, the Department will not approve any requests for increase in capacity or for additional capacity of additional licenses while civil penalties remain unpaid.

Child Care Providers can now sign up for Quarterly Updates and PINS through the DSS website. Please go to www.ccld.ca.gov and click on Child Care, go under Quick Links and Quarterly Updates, click on “Receive Important Updates” then enter your email address and choose which program(s) you would like to subscribe to and click “subscribe”. Duty Officer: (619) 767- 2248, Monday thru Friday 8am-5pm.



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.

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.

SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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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: 01/16/2024
NARRATIVE
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Licensee was informed of the 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.

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.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2024 04:46 PM - It Cannot Be Edited


Created By: Grace Curtis On 01/16/2024 at 03:38 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: GHOLAMI, ZAHRA FAMILY CHILD CARE
FACILITY NUMBER: 376100913

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
102370 Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Resident Salda Ayoubi does not have a criminal record clearance and is not associated to the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2024
Plan of Correction
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The licensee states that she will send LPA verification that Asiya Ayoubi has been fingerprinted and associated to the facility by 1/17/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tashima Daniel
LICENSING EVALUATOR NAME:Grace Curtis
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/16/2024 04:46 PM - It Cannot Be Edited


Created By: Grace Curtis On 01/16/2024 at 03:43 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: GHOLAMI, ZAHRA FAMILY CHILD CARE
FACILITY NUMBER: 376100913

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
1596.8662(b)(1)

On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The licensee does not maintain current mandated reporter certification. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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The licensee states that she will take mandated reporter training and submit a copy of her current completion certificate to LPA via email by 1/26/24.
Type B
Section Cited
CCR
102419(d)(1)
102419 Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parents’ Rights, LIC 995A (8/06)... (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 children's files reviewed do not contain signed Notification of Parents' Rights forms (LIC995A). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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The licensee states that she will submit signed Notification of Parents' Rights forms (LIC995A) for C1-C5 to LPA via email by 1/26/24.
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:Tashima Daniel
LICENSING EVALUATOR NAME:Grace Curtis
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2024 04:46 PM - It Cannot Be Edited


Created By: Grace Curtis On 01/16/2024 at 03:56 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: GHOLAMI, ZAHRA FAMILY CHILD CARE
FACILITY NUMBER: 376100913

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
102425 INFANT SAFE SLEEP
(c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and licensee statement, the licensee did not comply with the section cited above in 2 out of 2 infants under 12 months do not have a completed Infant Sleep Plan (LIC9227) on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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The licensee states that she will submit completed Infant Sleep Plans, LIC9227 for C4 & C5 to LPA via email by 1/26/24.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
102425 INFANT SAFE SLEEP
(j) The provider shall supervise infants while they are sleeping and adhere to the following requirements: (2) The provider shall check and document the following: (D)Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:c. Time of each 15-minute check.


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on record review and licensee statement, the licensee did not comply with the section cited above in 3 out of 3 infant files reviewed do not contain 15 minute sleep documentation. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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2
3
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The licensee states that she will submit 15 minute sleep documentation for C1, C4 & C5 to LPA via email by 1/26/24.
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:Tashima Daniel
LICENSING EVALUATOR NAME:Grace Curtis
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
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