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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002120
Report Date: 10/24/2024
Date Signed: 10/24/2024 03:55:20 PM

Document Has Been Signed on 10/24/2024 03:55 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CHAM, DELBAR KHOSRAVIFACILITY NUMBER:
414002120
ADMINISTRATOR/
DIRECTOR:		CHAM, DELBAR K.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 556-1428
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 14TOTAL ENROLLED CHILDREN: 2CENSUS: 2DATE:
10/24/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Delbar ChamTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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On October 24, 2024, at approximately 2:20pm, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced annual inspection and met with licensee Delbar Cham, and purpose of inspection was explained. Present during today’s visit was Licensee and 2 children (1 infant & 1 preschool age). Facility is operating within capacity and ratio requirements on this day. All adults living in home have criminal background clearances. Childcare hours of operation are Monday - Friday from 8:00am to 5:00pm.


LPA and licensee toured the indoors and outdoors of the home for health and safety hazards. Home is a one-story home. Day Care Area: living room, dining room, bedroom #1(for napping), bathroom, bonus room and backyard. Per licensee, kitchen is only used for hand washing purposes. Licensee stated due to low enrollment, bonus room is not currently being used. LPA observed kitchen cabinets to be secured with child safety latches and child proof stove knob covers. LPA observed some drawer latches to be broken, LPA reminded licensee to replace broken childproof latches. Off Limits Areas: bedroom #2, bedroom #3 and garage. Isolation area for sick children is in living room and away from other children. Fireplace is in living room is properly barricaded with a glass screen. LPA reminded licensee to replace edge protector around fireplace, technical assistance provided. Home is well light and has proper ventilation. LPA observed electrical outlets are secured with furniture. There are plenty of age-appropriate toys, books, child size furnishings, and playpen. Per licensee, licensee rotates toys from bonus room into living room. Currently no children are potty trained or using the bathroom. The backyard is equipped with plenty of age-appropriate toys which includes a small slide structure, mid-size slide, child size outdoor tables and ride on toys all in good condition. Backyard has a cement patio area, and the surrounding area is grass to cushion falls. Entire backyard is surrounded with a 5 ft. brick fence. LPA did not observe any pools, spas, or other bodies of water.

Cont. page 2.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHAM, DELBAR KHOSRAVI
FACILITY NUMBER: 414002120
VISIT DATE: 10/24/2024
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Home is equipped with a working dual carbon monoxide/smoke detector. LPA observed a fully charged fire extinguisher located on wall at entrance to home. LPA reviewed first aid kit and kit is fully stocked. Licensee maintains a landline and cell phone on the premise. Per licensee, there are no weapons or firearms in the home. Licensee provides sheets for children in care and washes them on a weekly basis or as needed.

LPA reviewed 2 children’s files. LPA issued technical violation for missing immunization record. Per licensee, licensee maintains liability insurance via Markel insurance. Licensee maintains an updated Children’s roster. Licensee CPR/FA expiration date is 05/2026. Licensee Mandated Reporter training expires 07/2025. Licensee provides meals for children in care, which includes breakfast, lunch and two snacks. LPA reminded licensee any food brought from home must be labeled and stored properly. LPA observed Childcare License, Emergency Disaster Plan (LIC610A) and Parent's rights posted. Last emergency drill was conducted on 10/11/2024 and is properly documented. LPA reminded licensee to maintain sleeping logs for all infants under 24 months old.

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 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's reviewed AB 1207 with the Licensee.

Cont. page 3...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHAM, DELBAR KHOSRAVI
FACILITY NUMBER: 414002120
VISIT DATE: 10/24/2024
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As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. LPA reminded licensee about Mandated Reporter training available www.mandatedreporterca.com

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. LPAs also informed licensees 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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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

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.

During the exit interview, the LICENSEE, Delbar Cham, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



No deficiencies were issued today under Title 22 Division 12 of the California Code of Regulations.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Delbar Cham.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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