<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002120
Report Date: 07/07/2023
Date Signed: 07/07/2023 01:44:02 PM

Document Has Been Signed on 07/07/2023 01:44 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CHAM, DELBAR KHOSRAVIFACILITY NUMBER:
414002120
ADMINISTRATOR:CHAM, DELBAR K.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 556-1428
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 14TOTAL ENROLLED CHILDREN: 514CENSUS: 2DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Delbar ChamTIME COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On July 7, 2023, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced annual inspection. LPA met with Licensee Delbar Cham and purpose of visit was explained. Present today is Licensee, Licensee’s spouse and 2 children (1 infant & 1 preschooler). Licensee is operating within capacity and ratio requirements on this day. All adults in home have criminal record clearances on file with the department. Licensee’s hours of operation are Monday– Friday 8:00am to 5:00pm.

LPA and Licensee toured the home for health and safety hazards. This one-story home is owned by Licensee. Day Care Areas: living room, dining room, kitchen (for hand washing), bonus room, bathroom, master bedroom(napping only) and backyard. Off Limits Areas: Bedroom #2, bedroom #3 and garage. Fireplace in living room is properly barricaded. The home is in good repair and has proper temperature and ventilation. Cleaning supplies and other potentially harmful items are stored inaccessible to the children. There are plenty of age-appropriate toys, child size furnishings, learning material, playpens, and sleeping cots. Licensee provides sheets and washes weekly. Backyard has a swing set, slide and plenty of outdoor toys in good repair. Outdoor play area has grass to cushion falls and concrete flooring. Backyard is fenced off with a 5 ft. fence. There are no spas, pool or other bodies of waters.

The home is equipped with a working dual carbon monoxide/smoke detector and a fully charged fire extinguisher located in kitchen. Isolation area for ill children is in Master bedroom away from other children. First aid kit is fully stocked with supplies. Licensee uses a cell phone and understand phone is to stay at home during daycare hours. Per licensee there are no weapons or firearms in the home.

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 resources. LPA discussed sleeping logs, technical violation issued, and LIC9227 Infant sleep plan.

Cont. page 2…
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHAM, DELBAR KHOSRAVI
FACILITY NUMBER: 414002120
VISIT DATE: 07/07/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2…

LPA reviewed 5 children’s records, one child is missing immunization records, technical assistance issued. Licensee CPR/First Aid is current and will expire on 05/2024. Licensee will complete Mandated Reporter training and submit certification to LPA, technical assistance issued. Licensee provides and cooks meal for children in care. Children’s roster was reviewed and is up to date. LPA reminded Licensee to document emergency drill, technical assistance issued. Licensee has liability insurance via Acord/Markel Insurance Company.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. Where 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 and Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

LPA reviewed AB 1207 with the Licensee. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

Cont. page 3...

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHAM, DELBAR KHOSRAVI
FACILITY NUMBER: 414002120
VISIT DATE: 07/07/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 3...

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

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.



A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

As of today, based on observation and file reviews, facility is currently in substantial compliance with title 22.

Exit interview conducted and report was reviewed with the Licensee, Delbar Cham.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7