434403754-10-24-2024-07-CC-JBER-DACQPJ-20241024122051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434403754
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:21:12 PM

Document Has Been Signed on 10/24/2024 12:21 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	HAGHIGHI, FERESTEH & KHAKPOUR, KHOSROW		FACILITY NUMBER:	434403754
ADMINISTRATOR/ DIRECTOR:	FERESTEH & KHOSROW		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 269-9815
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 12	DATE:	10/24/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Haghighi, Fereshteh & Khakpour, Khosrow		TIME VISIT/ INSPECTION COMPLETED:	12:30 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	Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Haghighi, Feresteh & Khakpour, Khosrow for an unannounced Annual Inspection. LPA was granted access to the home by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were 12 children (10 preschool aged / 2 infants) and 3 staff (2 licensees and one helper) present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday, 07:30AM-5:30PM. There are no active waivers or exceptions. Licensee states that adults, over the age of 18, residing in the home are: the two licensees only. All adults residing in the home have Criminal Background Check Clearance and signed Criminal Record Statements (LIC508). 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. LPA reviewed facility roster, which was created by the licensee but did include all required items that is listed in the LIC9040. LPA did print out a blank copy and leave it with the licensee to transfer information over to the LIC9040. The last fire/disaster drill was conducted on 10/08/2024 and the Earthquake fire drill was scheduled for today. Licensee conducted the earthquake drill in front of LPA. All children knew who their partner was and moved swiftly and calmly to get under the table until Fereshteh told them it was safe to come out. Licensee also demonstrated the fire drill and children knew exactly what to do when they heard the alarm. They found their buddies and entered into a line and calmly exited the house through the back bedroom to the patio door that opens to the backyard. This is compliant with the six month requirement for homes. Continued on Page 2

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HAGHIGHI, FERESTEH & KHAKPOUR, KHOSROW	FACILITY NUMBER: 434403754
	VISIT DATE: 10/24/2024

NARRATIVE

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LPA observed a fully charged 3A40BC fire extinguisher however, it was manufactured in 2020 and licensee stated it has not been serviced. LPA explained the regulation required the fire extinguisher to be serviced annually or replaced with the receipt available to verify date of purchase. Facility had a functioning smoke detector and carbon monoxide detector. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. The Licensee states that there are no weapons or firearms in the home. 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/.

Indoor areas of the home were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Off-limits areas of the home (indoors): Garage. There are no open-faced heaters in the home. Licensee has a fireplace and it is barricaded from children in care and cannot be accessed. Licensees understand that it cannot be used during day care hours. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. Drinking water is readily available for children in the facility via water pitchers and disposable cups kept on the table. Personal sippy cups are also kept in the fridge for children and all are labeled with child's names. The bathrooms in the home are clean, sanitary, and operable. The Licensee has a working telephone in the facility that is a land line (408) 269-9815. Licensee stated she communicates with parents through the land line daily. There are no stairs in the home.

The backyard area of the home was inspected. LPA observed sufficient play-equipment and supplies for the children that are in good condition and age-appropriate. Off-limit areas outside of home include: both side yard areas and front yard. No outdoor bodies of water were observed during today's inspection.

Infant Safe Sleep regulations (PIN 20-24-CCP) were discussed with the Licensee, including the Individual Infant Sleeping Plan (LIC9227). LPA reminded Licensee that infants up to 12 months of age should be placed on their back to sleep, that cribs should be free of all loose articles and hanging objects, and that infants should not be swaddled. Infants should be supervised while sleeping and documentation of sleep checks every 15 minutes should remain in the infant’s file. Documentation should include the time of the check, the infant’s physical condition, and initials of the staff member checking on the infant. Licensee stated she does not have any infant sleep logs for the two infants in care.

Continued on Page 3

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HAGHIGHI, FERESTEH & KHAKPOUR, KHOSROW	FACILITY NUMBER: 434403754
	VISIT DATE: 10/24/2024

NARRATIVE

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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 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.

6 children’s files were reviewed during today's inspection and all required documents were present, except the sleep check documentation for all infants. The following documents were present: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization Records (PM286). All files also included an agreement for care.

All staff files (2 licensees and one helper) were reviewed. Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza vaccinations will be completed for next week. LPA asked licensee to provide proof of completion by 10/31/2024. All staff member present had current CPR/First-Aid that expires 05/04/2026. The Licensees and helper have not completed the Mandated Reporter training since 2022. LPA reminded licensees that all staff must renew the mandated reporter training every 2 years.

Supervision of children was discussed with Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. LPA observed a letter in all the children's files stating licensee may leave during nap time for appointments and errands. However, spouse stays in the home during that time along with the hired helper. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.
The Licensee confirmed that there are no Registered Sex Offenders (RSO) living in the facility and LPA completed the RSO search on 10/18/2024 and verified no RSO's are listed at this property.
Continued on Page 4

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HAGHIGHI, FERESTEH & KHAKPOUR, KHOSROW	FACILITY NUMBER: 434403754
	VISIT DATE: 10/24/2024

NARRATIVE

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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Due to today's inspection, deficiencies have been issued: two Type B citations and two technical violations. Details of these deficiencies are attached in the following pages.

Exit interview conducted with licensees and report was reviewed and provided along with appeals rights.

NOTICE OF SITE VISIT WAS PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.

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.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
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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Document Has Been Signed on 10/24/2024 12:21 PM - It Cannot Be Edited

Created By: Jennifer Beehler On 10/24/2024 at 11:10 AM

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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HAGHIGHI, FERESTEH & KHAKPOUR, KHOSROW	FACILITY NUMBER: 434403754
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(a)(3)

Infant Safe Sleep

(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above in 2 out of 2 cribs. Cribs did not have a mattress and the sheet was loose and not tight fitting, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	Mattress must be placed in cribs with tight fitting sheets. Licensee to send a picture verifying this has been completed.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensees did not comply with the section cited above in 3 out of 3 staff people have not completed the mandatory 2 year completion of a mandated reported training class which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	All staff people at facility to complete Mandated Reporter Training and a copy of the certificates provided to LPA to confirm.

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:

Joel Segura

LICENSING EVALUATOR NAME:

Jennifer Beehler

LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

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