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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627890
Report Date: 01/20/2023
Date Signed: 01/20/2023 01:29:32 PM

Document Has Been Signed on 01/20/2023 01:29 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:MORTAZAVI, SAMAR FAMILY CHILD CAREFACILITY NUMBER:
376627890
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 3DATE:
01/20/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Licensee, Samar MortazaviTIME COMPLETED:
01:30 PM
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On 1/20/23 at 11:45 AM LPA Saraliz Velando conducted a unannounced Case Management/Increase in capacity inspection of home with Samar Mortazavi. The purpose of the visit is to ensure that the home is compliant with standards established in CCR, Title 22, Division 12, Chapter 3. Licensee was in ratio with 3 minor children in care. The 2-story, 4 Bedroom, and 4 bathroom home, was toured and inspected to ensure a safe and healthful environment for children. The 3A10BC fire extinguisher, smoke detector and carbon monoxide detector are operational and meet regulations. Licensee states that there are no weapons in the home and LPA did not observe any. There are no bodies of water on the premises.

Licensee CPR and First aid certifications are valid through January 2025. The following areas are used for the childcare: Living room, Kitchen, Dining room, bedroom 4, bathroom 4, and backyard. Off limit areas: All second floor bedrooms, bathrooms, and Garage. All poisons, cleaners, and hazardous items are inaccessible to children by latches and out of reach of children. Electrical outlets are tamper resistant.. There are sufficient and appropriate toys and equipment available in the home and backyard for children’s use. Outdoor play area is a fenced backyard. Licensee reminded that visual supervision is required at all times when children are outside.

All adults in the facility have submitted or been cleared for criminal record and child abuse index clearances or exemptions. Licensees were 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. Fire clearance was approved on 11/29/22.

SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Saraliz Velando
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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: MORTAZAVI, SAMAR FAMILY CHILD CARE
FACILITY NUMBER: 376627890
VISIT DATE: 01/20/2023
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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, ensure that all adults living or working in the home have criminal background clearances associated to the facility, 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 and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov. LPA provided website: https://www.cdss.ca.gov/inforesources/community-care-licensing to receive important updates and information.
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.

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.

Per applicant operating hours are from 8:00 AM – 6:00 PM, Monday – Friday. LPA reviewed children’s records, capacity limitations, supervision, emergency drills. Last drill conducted 9/30/22. LPA discussed child passenger law, unusual incidents reporting, mandated reporting, SIDS, and Shaken Baby Syndrome.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Saraliz Velando
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: MORTAZAVI, SAMAR FAMILY CHILD CARE
FACILITY NUMBER: 376627890
VISIT DATE: 01/20/2023
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Applicant is reminded that corporal punishment, smoking, walkers, exersaucers, jumpers and bouncy seats shall never be permitted during daycare operation. Licensee was given heat related tips. Licensee reminded that garage is never to be used.

The facility is in substantial compliance and no deficiencies are sited at this time. A large license is recommended and may be issued after a thorough file review.

Exit interview conducted and report was reviewed with the licensee, Samar Mortazavi. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Saraliz Velando
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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