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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004999
Report Date: 06/13/2023
Date Signed: 06/13/2023 04:54:20 PM

Document Has Been Signed on 06/13/2023 04:54 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:GHASEMZADEH, MOJGANFACILITY NUMBER:
414004999
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Mojgan GhasemzadehTIME COMPLETED:
12:15 PM
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On June 13, 2023, at approximately 8:45AM, Licensing Program Analysts (LPA) Maria Olguin-Leon conducted an announced, pre-licensing inspection. LPA met with applicant, Mojgan Ghasemzadeh and explained the purpose of the inspection.

Applicant submitted original family childcare home application to department on March 27,2023. On May 19, 2023, applicant submitted a new application for new address. Applicant plans to operate Monday to Sunday from 8:00am to 5:30pm. Applicant plans to care for children ages 6 months to 12 years old.

With applicant, LPA inspected the indoors and outdoors of the home for health and safety hazards. Applicant rents this single-story home that consists of a living room, dining room, kitchen, 3 bedrooms and 2 bathrooms. The DAY CARE AREAS are the living room (playroom), dining room, kitchen/hallway (walk through to backyard), bedroom #1, bathroom #1 and outdoors. Outdoor is gated and equipped with plenty of toys for children. The OFF-LIMIT AREAS bedroom #2, and bedroom/bathroom #3. Applicant was notified any off-limit areas are not to be used as a day care area without prior approval from department.

LPAs observed the following: Home was clean and orderly. Playroom area (living room) has bookcase equipped with book and toys. Bedroom #1 is equipped with a variety of age-appropriate toys, two cribs, changing table and garbage can with a tight-fitting lid. Per applicants,changing table will be disinfected after each use. Outdoor is equipped with small playhouse and slide and ground surface has artificial grass to cushion falls.

Home has ventilation and lighting throughout. Per applicant, off-limit areas will remain locked during operating hours with child proof doorknobs or closed doors. All detergents, cleaning compounds, medications and other items which could pose a danger are stored inaccessible to children behind child safety locked cabinets and/or located in off limit areas. Per applicants, there are no weapons or firearms in the home.

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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 4
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: GHASEMZADEH, MOJGAN
FACILITY NUMBER: 414004999
VISIT DATE: 06/13/2023
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Home is equipped with two dual carbon monoxide/smoke detectors, one in bedroom #1 and one in kitchen hallway. LPA observed a first aid kit with necessary supplies. Applicant uses a designated cell phone and is aware the cell phone must stay within the home during the day care hours. Isolation area for sick children will be in living room away from other children and where applicant can supervise all children in care.

LPAs reviewed the LIC311D, Records to Keep in Your Family Child Care Home, children’s forms/ records, facility forms, and information to be posted. Applicant’s CPR/First Aid certification is current and will expire 01/2025. Applicants Mandated Reporter training certificates (AB1207) is current that will expire 03/2025.

LPA and applicant discussed licensing regulations and the capacity requirements. Any children under 10 years of age that live in the home, will be counted in overall capacity. Applicant plans to provide a meals: breakfast, lunch and two snacks. Children also have the option to provide their own meals. LPAs discussed sanitation and allergies with applicants. LPA reminded Applicant to label all food brought from home.

Applicant understands the required emergency disaster drills are to be conducted and documented at least once every six months. Applicant understands that the use of baby walkers, bouncers, jumpers and similar items are not to be used for children in care. Smoking is prohibited inside a Family Childcare Home.

Applicant were reminded 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 for influenza, pertussis and measles or qualifies for an exemption pursuant to Health and Safety Code 1596.7995 and 1597.662.

Applicant were reminded that all adults 18 years and over living or working in the home, including employee and volunteers, must obtain criminal 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.



LPA discussed the safe sleep regulations with applicant and discussed Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. .

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

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: GHASEMZADEH, MOJGAN
FACILITY NUMBER: 414004999
VISIT DATE: 06/13/2023
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LPA informed the applicant of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility plans to provide Incidental Medical Services-IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. A Plan for Providing IMS must be submitted to the Department. The following information regarding Americans with Disabilities Act (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: www.ada.gov/childqanda.htm.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important communication platform. To receive important license-related information to licensed facilities, visit the CCLD important information website at https://www.cdss.ca.gov/inforesources/community-care-lciensing/subscribe and select the Child Care option to receive email communication.


Prior to recommended licensure, following must be completed:

-Secure fireplace screen

-Barricade wall heater

-install outlet covers

-Secure backyard, block access to underneath deck, cover trim protruding from ground, remove piece of wood in walkway

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

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: GHASEMZADEH, MOJGAN
FACILITY NUMBER: 414004999
VISIT DATE: 06/13/2023
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-install a 2A10BC or larger size fire extinguisher in the home.


-install corner protectors on bench in living room

-Posting of required licensing documents

-Fingerprint clearance

-toys

Exit interview was conducted with the applicant, Mojgan Ghasemzadeh



A copy of this report was provided.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4