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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404138
Report Date: 09/05/2024
Date Signed: 09/05/2024 12:19:39 PM

Document Has Been Signed on 09/05/2024 12:19 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:TAYEBI, HAJARFACILITY NUMBER:
434404138
ADMINISTRATOR/
DIRECTOR:		HAJAR TAYEBIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 261-8986
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 6DATE:
09/05/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:23 AM
MET WITH:Hajar TayebiTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Annual/Random inspection. LPA met with Hajar Tayebi and explained the reason for the inspection. Licensee arrived at the home when LPA got to the home. Upon entrance, Assistant was present with five children, whom one was infant age. All adults present during today's inspection have cleared criminal record and child abuse index.

There is an area to post required postings, such as license and notification of parent's rights. The hours of operation are Monday through Friday 8AM to 5PM. Licensee owns the home and does not liability insurance.

LPA toured the inside and outside of the home. The off-limit areas of the home are the kitchen, dining room, family room, living room, master bedroom, bedroom #2, bedroom #3, two bathrooms between the master bedroom and bedroom #2, and laundry area. Licensee is only using the converted garage for the children, which has a half bathroom for the children. LPA discussed with Licensee that the gate or the door leading to the main home needs to be closed to make the rest of the home off-limits. There are toys and equipment for children. Licensee provides lunch and snacks to children. There is a mini fridge located in the half bathroom and a fridge in the kitchen. There is a fire extinguisher and smoke detector. LPA discussed with Licensee that the fire extinguisher needs to serviced every year or proof of new fire extinguisher There is no carbon monoxide detector in the home. Licensee stated that there are no weapons, such as firearms, stored in the home. Licensee does have a pet in the home.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: TAYEBI, HAJAR
FACILITY NUMBER: 434404138
VISIT DATE: 09/05/2024
NARRATIVE
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-------------CONTINUATION OF 809 DATED 09/05/2024 PAGE 1----------------

The backyard is used and is fenced. The off-limit areas outside are the gym area, shed, and the left side of the yard. The shed was closed, but not locked. There were tools and pesticides inside. Licensee placed a lock on the shed during today's inspection. There were no bodies of water observed during today's inspection.

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. Licensee does not document the time checked when infant is sleeping.

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/.

Licensee does not transport children, but understands that children cannot be left alone and unattended in parked vehicles.

A copy of the facility roster was obtained. Four children's files were reviewed. The records reviewed include but not limited to LIC 627: Consent for Emergency Medical Treatment and immunization records. All children did not have LIC 627 in file and C-1 did not have a file.
---------------CONTINUES ON 809 DATED 09/05/2024 PAGE 3--------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
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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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: TAYEBI, HAJAR
FACILITY NUMBER: 434404138
VISIT DATE: 09/05/2024
NARRATIVE
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------------CONTINUATION OF 809 DATED 09/05/2024 PAGE 2----------------

Licensee and her assistant's file was also reviewed. Licensee and her assistant have a valid CPR/1st Aid. Licensee's CPR/1st Aid expires on 03/2026 and her Assistant's CPR/1st Aid expires on 04/2026. Licensee and her Assistant have immunization records for measles and pertussis. LPA discussed with Licensee to have proof of influenza every year or a sign statement that influenza was declined on file. Licensee and her assistant do not have Mandated Reporter training certificate on file. LPA discussed with Licensee that the Mandated Reporter training required renewal every two years and can be completed at mandatedreporterca.com.

The adults living in the home are Licensee and her adult child. All adults have cleared criminal record, child abuse index, and TB test. 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.

During the exit interview, the Licensee, Hajar Tayebi, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA also discussed with Licensee that she cannot be gone more than 20 percent of the hours of operation per day.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
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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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: TAYEBI, HAJAR
FACILITY NUMBER: 434404138
VISIT DATE: 09/05/2024
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----------------CONTINUATION OF 809 DATED 09/05/2024 PAGE 3-----------

Licensee will submit the following:
- LIC 627 for all children by 09/19/2024
- C-1's file by 09/19/2024 or letter that she is not enrolled
- Mandated Reporter training for herself and her assistant by 10/22/2024
- proof of carbon monoxide detector by 09/09/2024
- fire extinguisher was serviced and purchase of new fire extinguisher by 09/19/2024

As a result of this inspection, Type A and Type B citations were issued. Exit interview conducted and report was reviewed with Licensee Hajar Tayebi. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip informed Licensee Hajar Tayebi that this report dated 09/05/2024 documents one Type A citations which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Licensee to provide a copy of this licensing report dated 09/05/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 09/05/2024 12:19 PM - It Cannot Be Edited


Created By: Samantha Yip On 09/05/2024 at 11:13 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: TAYEBI, HAJAR
FACILITY NUMBER: 434404138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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By POC 09/09/2024, Licensee will purchase a carbon monoxide detector and submit proof to Licensing.
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 09/05/2024 12:19 PM - It Cannot Be Edited


Created By: Samantha Yip On 09/05/2024 at 11:13 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: TAYEBI, HAJAR
FACILITY NUMBER: 434404138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. There is a shed in the backyard that has tools and pesticides that was not locked.
POC Due Date: 09/06/2024
Plan of Correction
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Deficiency corrected during today's inspection. Licensee placed a lock on the shed.
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
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Based on record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. Licensee last completed the Mandated Reporter training on 08/23/2022 and Assistant does not have Mandated Reporter training certificate on file.
POC Due Date: 10/22/2024
Plan of Correction
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By POC 10/22/2024, Licensee and her assistant will complete Mandated Reporter training and submit proof to Licensing.
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:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 09/05/2024 12:19 PM - It Cannot Be Edited


Created By: Samantha Yip On 09/05/2024 at 11:13 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: TAYEBI, HAJAR
FACILITY NUMBER: 434404138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in five out of five persons, which poses a potential health, safety or personal rights risk to persons in care. All children did not have LIC 627 on file and one child did not have a file.
POC Due Date: 09/19/2024
Plan of Correction
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By 09/19/2024, Licensee will have parents fill out LIC 627 and submit proof to Licensing. Licensee will submit LIC forms for C-1.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in one out of one persons, which poses a potential health, safety or personal rights risk to persons in care. Licensee does not document the date, name of the child, and time checked when infant is napping.
POC Due Date: 09/19/2024
Plan of Correction
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By POC 09/19/2024, Licensee will complete sleep check every 15 minutes and document the name of the child, date, and time checked. Licensee will submit proof to Licensing.
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:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


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