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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376101939
Report Date: 03/18/2024
Date Signed: 03/18/2024 11:52:54 AM

Document Has Been Signed on 03/18/2024 11:52 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:GOSHTASB, NEGIN FAMILY CHILD CAREFACILITY NUMBER:
376101939
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Negin GoshtasbTIME COMPLETED:
12:20 PM
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On 3/18/24 at 10:50 AM, Licensing Program Analyst (LPA) Annette Sutherland conducted a change of location pre-licensing inspection. Upon arrival, LPA was greeted by applicant Negin Goshtasb. Also present was licensee’s husband Kooosh Rashidi and mother in law Rouhangiz Mojarradi. The 3-bedroom, 2-bathroom, one level home was toured and inspected to ensure an environment safe for the care and supervision of children.
License has provided adequate space for the children to eat, sleep and play within the home. Areas used for childcare include the following areas: living room, bathroom #1, bedroom #2 and backyard. Off limit areas include Kitchen, family room, master bedroom, bathroom, bedroom #1 and garage. Off-limit areas have been made inaccessible with the use of doorknob covers and safety gates. The facility has sufficient toys and equipment available. There is a fully charged fire extinguisher, smoke and carbon monoxide detector that meet requirements and are operational. Poisons, cleaning compounds, medications and other hazardous items are inaccessible. Adequate heating and ventilation are provided. There is a working telephone/email address. Applicant stated there are no firearms and weapons in the home. No bodies of water on the property.
A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal records and child abuse clearances or exemptions. Applicant owns the home and has provided proof of control of property . First Aid and CPR expire on 1/21/25.
The applicant is exempt Mandated Reporter Training as primary language is Farsi. Staff immunization requirements per SB792 were met. All required postings are posted.
LPA informed Applicant that all unusual incident reports shall be submitted to Licensing office via email at SDIncidentReports@dss.ca.gov or via fax at (619)767-2203.
SUPERVISORS NAME: Joelle Redding
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GOSHTASB, NEGIN FAMILY CHILD CARE
FACILITY NUMBER: 376101939
VISIT DATE: 03/18/2024
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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.

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 MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

No corrections are needed.

A license for 8 children may be issued upon final file review. The licensee was reminded that annual fees are due on the date they were licensed every year. An exit interview was conducted with Licensee. Appeal Rights (LIC9058) were given along with the report (LIC809) to the Licensee.
SUPERVISORS NAME: Joelle Redding
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GOSHTASB, NEGIN FAMILY CHILD CARE
FACILITY NUMBER: 376101939
VISIT DATE: 03/18/2024
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The duty officer number is (619)767-2248. 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. Applicant was reminded of requirements for children’s records, facility roster, child abuse and unusual incident reporting, immunization's, car seat law, shaken baby syndrome, and SIDS. Applicant was reminded that corporal punishment, smoking, baby walkers, exersaucers, bouncy seats and baby jumpers are not allowed in day care. The ABC’S of Safe Sleep: Sleep is Safest: Alone, on their Back in an empty Crib on a firm mattress. Applicant shall comply with all regulations and laws governing family childcare homes and be financially secure to operate a family childcare home for children.
Applicant 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 reviewed with applicant the LIC 311D, Forms/Records to Keep in Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.
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.
LPA discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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: Joelle Redding
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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