434409641-7-22-2021-52-CC-MPRE-C56QRJ-20210722122402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409641
Report Date: 07/22/2021
Date Signed: 07/22/2021 12:24:07 PM

Document Has Been Signed on 07/22/2021 12:24 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	LASHKARI, KHADIJEH & KHOSROW		FACILITY NUMBER:	434409641
ADMINISTRATOR:	KHADIJEH & KHOSROW LASHKAR		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 855-9351
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94303
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	07/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Khadijeh Lashkari		TIME COMPLETED:	12:25 PM

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On 7/22/2021 at 10:09am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Khadijeh Lashkari for an unannounced annual inspection. Present during the inspection was the Licensee and her fingerprint cleared assistant Noushin Shobgard Daem. There were four (4) infants and one (1) preschool child present during the inspection. Licensee lives in the home with her husband Khosrow Lashkari, who is also a Co-Licensee. The Licensee’s home was toured for a health and safety inspection. The operating hours are 8:00am – 5:30pm Monday – Friday.

ON LIMITS AREA: Living Room, Family Room, Dining Room, Kitchen, Downstairs Bathroom, Both Downstairs Bedrooms and Backyard

OFF LIMITS AREA: Entire 2^nd Floor and Garage

ISOLATION AREA: Living Room

The facility is a two story home owned by the Licensee. The inside of the home is observed to be neat, clean with ample age appropriate materials for the children that are safe and clean. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there no firearms and no pets in the facility.

The home has one (1) fully charged 3A40BC fire extinguisher located in the closet in between the living room and family room. There is a portable fire alarm hanging on the poster board next to the door leading to the backyard. There is one (1) working smoke detector above the stairs and one in the kitchen. There is a working carbon monoxide detector in the living room and one in the kitchen. The home is equipped with central heat and air for proper ventilation.

Cont on 809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: LASHKARI, KHADIJEH & KHOSROW	FACILITY NUMBER: 434409641
	VISIT DATE: 07/22/2021

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At 11:37am LPA obtained the facility roster, assistants file, and the children’s files. All files are complete. The Licensee’s Health and Safety training has been completed and CPR and First Aid training is complete with an expiration date of 2/2022. Licensee’s fire and disaster drill log is complete with the last drill logged 7/13/2021. All required forms are posted and visible for public view on the living room walls.

Licensee was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed as well. Licensee was reminded that when any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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: http://www.ada.gov/childqanda.htm.

Licensee is reminded that ALL Licensees, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3,000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.
Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six months and documented. The licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

This report was read and given to the Licensee for a signature. There are no deficiencies being cited today. This report shall remain on file for 3 years. Appeal Rights were provided and exit interview conducted. A Notice of Site visit was given and must be posted for 30 days.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

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