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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004999
Report Date: 11/14/2024
Date Signed: 11/14/2024 04:33:34 PM

Document Has Been Signed on 11/14/2024 04:33 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:GHASEMZADEH, MOJGANFACILITY NUMBER:
414004999
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
11/14/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:36 PM
MET WITH:Mojgan GhasemzadehTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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On Novermber 14,2024, at approximately 1:35pm, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced annual inspection and met with licensee, Mojgan Ghasemzadeh, and purpose of inspection was explained. Present during today’s visit was Helper and 8 children (5 infants and 3 preschoolers). LPA observed facility is operating over capacity limits. This is an immediate risk to children in care, a type A violation was issued today for this deficiency. Hours of operation are Monday– Friday, 8:00 am - 5:30pm.

LPA and licensee toured and inspected the indoors and outdoors of home for health and safety hazards. Home is a single level home. Day Care Areas: are bedroom #1(napping purposes), living room (playroom), dining room, kitchen/hallway (walk through to backyard), bathroom #1 and backyard. Licensee requested to add bedroom #2 to daycare areas for napping purposes only. LPA inspected bedroom #2 for health and safety hazards. LPA approved use of bedroom #2 for napping only. The Off-Limits Areas: are bedroom/bathroom #3. Isolation Area for ill children will be in the living room and away from other children. LPA observed home to be clean with proper lighting and ventilation. LPA observed wall heater in living room to be properly barricaded. LPA observed electrical outlets are secured with furniture and outlet covers. LPA observed stove equipped with child proof knobs for inaccessibility to children in care. Fireplace located in living room is barricaded with a screen and table. There are plenty of age-appropriate toys, books, child size furnishings, storage cubbies, cribs, and playpens. Outdoors play area is equipped with a playhouse, small play slide and ride on toys, all in good condition. Outdoor flooring is artificial grass to cushion falls. The remainder of outdoor flooring is dirt. LPA observed a large tree in backyard for providing shade to children in care. The entire backyard is surrounded with a 5 ft. fence. LPA did not observe any spas, pools, or other bodies of water.

Cont. page 2...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: GHASEMZADEH, MOJGAN
FACILITY NUMBER: 414004999
VISIT DATE: 11/14/2024
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LPA tested and observed a dual working carbon monoxide/smoke detector. A fully charged fire extinguisher is located on a wall of dining room. LPA reviewed first aid kit which is fully stocked with first aid supplies. Licensee uses a cell on the premises. Per licensee, there are no weapons or firearms in the home. Licensee provides sheets for cribs and playpens and are washed on a weekly basis.

LPA reviewed 8 children’s files and 1 staff file. Technical assistance was provided for forms missing in children’s files. LPA reminded licensee to keep updated and daily sleeping logs for all children under the age of 24 months. Licensee maintains a Children’s roster. Licensee CPR/First Aid is current and expires 01/2025. Licensee Mandated Reporter training expires 03/2025. Licensee provides meal to children in care, which includes breakfast, lunch and two snack. LPA observed Childcare License, Emergency Disaster Plan (LIC610A) and Parent's rights posted. Last emergency drill was conducted on 07/05/2024 and is properly documented. Per Licensee, liability insurance coverage is via Assure insurance.

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: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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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: GHASEMZADEH, MOJGAN
FACILITY NUMBER: 414004999
VISIT DATE: 11/14/2024
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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. LPA reminded licensee of banned equipment; Type B deficiencies were cited.

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, Mojgan Ghasemzadeh confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.




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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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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: GHASEMZADEH, MOJGAN
FACILITY NUMBER: 414004999
VISIT DATE: 11/14/2024
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**See following page for deficiencies cited against the facility today under CCR, Title 22, Div. 12, Chap. 1**

Type “A” deficiency was issued today. Licensee is advised to provide a copy of the Evaluation Report and all Type “A” Deficiencies cited, to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files.

A notice of site visit was given and must remain posted for 30 days. Appeal rights were provided to Licensee.

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

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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Document Has Been Signed on 11/14/2024 04:33 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 11/14/2024 at 04:16 PM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GHASEMZADEH, MOJGAN
FACILITY NUMBER: 414004999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA confirmed Licensee is operating over capacity with 5 infants, and 3 preschooler in care, which poses an immediate health, safety or personal rights risk to persons in care. which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 11/15/2024
Plan of Correction
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Licensee will dismiss two newly enrolled twin infants. Per licensee, licensee has applied for a large license and one infant is leaving at the end of the month.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Marie Rodriguez
LICENSING EVALUATOR NAME:Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


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