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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376626506
Report Date: 08/10/2022
Date Signed: 08/10/2022 11:27:22 AM

Document Has Been Signed on 08/10/2022 11:27 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:MASSOUDI, MAHTAB FAMILY CHILD CAREFACILITY NUMBER:
376626506
ADMINISTRATOR:MAHTAB MASSOUDIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 705-7577
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
08/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Mahtab Massoudi TIME COMPLETED:
11:35 AM
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On 8/10/22 at 8:57 AM Licensing Program Analyst (LPA) Annette Sutherland conducted an unannounced annual inspection with the Licensee. Upon arrival, LPA met with Licensee Mahtab Massoudi. Also, in the home was Licensee’s husband Kourosh Abram and minor son. Licensee was provided the Inspection Checklist (LIC 126). The 2-story home was toured and inspected to ensure an environment safe for the care and supervision of children. Present in the home were 10-day care children. The facility is within ratio and capacity. Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for childcare include Dining room (converted to napping room), family room, kitchen, 1 bathroom and 2nd part of backyard. Off limits areas include entire upstairs, garage, laundry room and half part of backyard with above ground hot tub and are inaccessible through use of safety gates and door locks. The staircase and fireplace are properly barricaded. The last Fire drill was conducted on 3/21/22. The licensee has sufficient toys and equipment available. The home has a fenced backyard divided in half. One half is for outdoor activities and has a separate entrance from inside the house. The other half has an in ground hot tub which is properly fenced and made inaccessible to children. LPA conducted childcare quality management interview with the Licensee. The smoke detector and carbon monoxide detector meet requirements and are operational. The fire extinguisher is not the correct size. All hazardous items were latched/locked and secured out of reach of children. Licensee states that there are no weapons in the home. First Aid and CPR certifications expire on 7/23/23 for Licensee and Husband. Licensee has required immunizations. Licensee has not completed Mandated Reporter Training but is reminded it must be completed every 2 years. Children’s and Staff records were reviewed and found to be in order.

Continued on LIC 809C
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
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: MASSOUDI, MAHTAB FAMILY CHILD CARE
FACILITY NUMBER: 376626506
VISIT DATE: 08/10/2022
NARRATIVE
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Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms; corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA reviewed Covid-19 guidelines with Licensee and provided Covid-19 resources. LPA directed Licensee to website: https://www.cdss.ca.gov/inforesources/community-care-licensing to receive important updates and information. 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 Childcare Licensing Safe Sleep web page 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.
LPA reviewed with Licensee the LIC 311D, Forms/Records. To Keep in Your Family Childcare Homes, children’s forms/records, facility forms/records, and information to be posted. 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 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 Childcare 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 Licensee with the following: childcare advocates-email address: childcareadvocatesprogram@dss.ca.gov .

Continued on LIC 809C
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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: MASSOUDI, MAHTAB FAMILY CHILD CARE
FACILITY NUMBER: 376626506
VISIT DATE: 08/10/2022
NARRATIVE
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 In addition, for general questions or questions regarding licensing requirements contact the Childcare Licensing Duty Line at (619) 767-2248.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Childcare 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 Childcare Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

See LIC809D for deficiencies cited & Technical Assistance attached.

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/inspection-process.

Exit interview conducted and report was reviewed with the licensee (name). A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2022 11:27 AM - It Cannot Be Edited


Created By: Annette Sutherland On 08/10/2022 at 10:45 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: MASSOUDI, MAHTAB FAMILY CHILD CARE
FACILITY NUMBER: 376626506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based upon LPAs observation and Licensee statement, the fire extinguisher is the wrong size and needs to be replaced, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2022
Plan of Correction
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Licensee will replace the fire extinguisher for size 2A10BC or larger and provide proof of required standards by sending a picture via e-mail to LPA Sutherland by 8/17/22 (Annette.Sutherland@dss.ca.gov).
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

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 as infant sleep logs have not been done for infants in facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2022
Plan of Correction
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Licensee will provide a copy of sleep logs for infants in care.
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:Monica Cuddy
LICENSING EVALUATOR NAME:Annette Sutherland
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022


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