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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376300461
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:47:17 PM

Document Has Been Signed on 04/26/2023 12:47 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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:KHAMOOSHIAN-RAHMATI GOVARI-ZAREEI FAMILY CCFACILITY NUMBER:
376300461
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 4DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Nasim KhamooshianTIME COMPLETED:
01:10 PM
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On date and time listed, Licensing Program Analyst (LPA) Keely Messerschmidt arrived at the facility to conduct an annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

· Normal days and hours of operation are: Monday through Friday 7:00am to 6:00pm

· Off-limit areas include: bedroom 1, kitchen, both living rooms, dining area, hall bathroom, side yard and garage

· The facility is licensed to have no more than 8 children as a small FCCH and is operating within the licensed capacity and appropriate ratios. There were 4 children present during the inspection.


· Appropriate supervision provided during this inspection

· A working telephone is present, and the current phone number is on file

· A fully charged fire extinguisher (2A:10BC) was observed. A smoke detector and carbon monoxide detector were present and tested by the Licensee during this inspection.

· Fireplace is properly screened to prevent access by children

· All hazardous items are stored inaccessible to children

· Toxins are locked

· There are no weapons in the home. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

· There are no stairs in the home.

SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 04/26/2023 12:47 PM - It Cannot Be Edited


Created By: Keely Messerschmidt On 04/26/2023 at 10:52 AM
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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: KHAMOOSHIAN-RAHMATI GOVARI-ZAREEI FAMILY CC
FACILITY NUMBER: 376300461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
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 or

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 1 out of 3 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Licensee agrees to have future employee get fingerprinted and background clearance with association to her facility by May 26th 2023.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


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Document Has Been Signed on 04/26/2023 12:47 PM - It Cannot Be Edited


Created By: Keely Messerschmidt On 04/26/2023 at 10:52 AM
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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: KHAMOOSHIAN-RAHMATI GOVARI-ZAREEI FAMILY CC
FACILITY NUMBER: 376300461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

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 3 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2023
Plan of Correction
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Licensee agrees to start immediately documenting all children 2 years and younger, the every 15 minute sleep checks.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day 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 in 2 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Licensee agrees to have herseld and future employee complete the Mandated Reporter Training and submit to LPA by 5/26/23.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


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Document Has Been Signed on 04/26/2023 12:47 PM - It Cannot Be Edited


Created By: Keely Messerschmidt On 04/26/2023 at 10:52 AM
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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: KHAMOOSHIAN-RAHMATI GOVARI-ZAREEI FAMILY CC
FACILITY NUMBER: 376300461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

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

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 1 out of 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2023
Plan of Correction
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Licensee agrees to have C4 parents complete LIC9227 and submit to LPA by 5/1/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Carlos Martinez
LICENSING EVALUATOR NAME:Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


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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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: KHAMOOSHIAN-RAHMATI GOVARI-ZAREEI FAMILY CC
FACILITY NUMBER: 376300461
VISIT DATE: 04/26/2023
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·Clean, safe and age appropriate toys

· Current roster on file

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted

· Documentation of fire and disaster drills on file – Last drill conducted on 4/23/23

· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· Verification of control of property on file

· Children’s records are complete- one infant missing LIC9227

· Employee’s records are complete- Licensee Mandated Reporter expired

· Mandated Reporter Training expired on 3/4/23

· Pediatric CPR and First Aid Card expire on 10/23/23

· Health & Safety Certificate - completed on 4/29/22


· Resident and/or staff records were reviewed and 2 of the 3 adults who require caregiver background checks have received all required clearances and/or exemptions. One adult was working with children who was not background checked and missing required clearance.
o In accordance with Title 22 Regulation, 101170(h) Violation of Section 101170(e) will result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the Department.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: KHAMOOSHIAN-RAHMATI GOVARI-ZAREEI FAMILY CC
FACILITY NUMBER: 376300461
VISIT DATE: 04/26/2023
NARRATIVE
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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

The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov



The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.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 [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.

Licensee 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.

Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.



The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: KHAMOOSHIAN-RAHMATI GOVARI-ZAREEI FAMILY CC
FACILITY NUMBER: 376300461
VISIT DATE: 04/26/2023
NARRATIVE
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See LIC 809D for cited deficiency. A Civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

An exit interview was conducted, and this report was reviewed with the licensee Nasim Khamooshian. Appeal rights were discussed and provided during the exit interview.



The Notice of Site Visit and Type A Deficiencies from today’s visit must be posted for 30 days. Failure to keep these posted for the entire 30 days will result in an immediate $100 civil penalty for each.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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