434409641-2-27-2023-52-CC-JPLA-CPFR8P-20230227114817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409641
Report Date: 02/27/2023
Date Signed: 02/27/2023 11:48:41 AM

Document Has Been Signed on 02/27/2023 11:48 AM - 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: 14	CENSUS: 6	DATE:	02/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Khadijeh Lashkari		TIME COMPLETED:	12:00 PM

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On February 27, 2023 at 9:30am, Licensing Program Analyst (LPA) Julia Placencia arrived at the facility unannounced to conduct a Required-1 Year Inspection. LPA met with licensee Khadijeh Lashkari. Also residing in the home is the licensee’s husband/co-licensee Khosrow Lashkari. The facility is a two story single family home. Hours of operation for child care are Monday through Friday, 7:30am to 5:30pm. The following was observed during today’s inspection:

Capacity/Staffing: The facility operates as a Family Child Care Home (large), which may have a maximum capacity of twelve (12) to fourteen (14) children. At time of inspection, there were six (6) children in care (four infants and two preschool age), and helper Noushin Shabgarddaem. The facility is in compliance with ratio and capacity limitations.

ON Limit areas (accessible to children in care): Family Room, Living Room, Dining Room (for sleeping infant in pack-n-play), Bedroom on first floor on left side of hallway, Bathroom on first floor, Backyard. The stairway had a child safety gate in place. LPA observed the facility to be clean and in good repair, with heating and ventilation for safety and comfort. There are ample age appropriate toys that are observed to be safe and in good condition. The fireplace is screened and barricaded by a table and chairs. The backyard has a fence surrounding the perimeter of the yard. There were no pools, hot tubs or other bodies of water. LPA did not observe any dangerous conditions, nor any hazardous or toxic items accessible to children in the ON Limit areas of the facility today.

OFF Limit areas (not accessible to children in care): Kitchen, Office on first floor, Entire second floor, Garage. OFF Limit areas are inaccessible by closed and/or locked doors and visual supervision. Licensee is advised to contact Licensing so that an inspection can be completed prior to changing an OFF Limit area to ON Limit.

***Continued on LIC 809C...

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

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: 02/27/2023

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Emergency Preparedness/Safety: Facility has a fully charged fire extinguisher. Smoke and carbon monoxide detectors were tested and found to be functioning. First aid supplies are available. A fire/disaster drill was last conducted on 2/1/23 and meets the six month requirement. Facility has phone service. Per licensee, there are no firearms in the home, and the Emergency Disaster Plan on file is current.

Staff Records Review: Licensee and all adults living and/or working in the home have proper criminal background clearances. Licensees and helper have current CPR/First Aid training, which expires 2/2024. Licensees and helper's mandated reporter training expires 7/31/23, and all are in compliance with the immunization law that pertains to day care providers.

Children’s Records Review: All required licensing documents were observed. Facility does not have Liability Insurance and Affidavits are in each child’s file. A facility roster is maintained.

Licensing Posting (required): Facility license, Notification of Parents’ Rights, Earthquake Preparedness.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm.

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 was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to also email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list.

***Continued on LIC 809C...

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

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: 02/27/2023

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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

The following deficiency was observed during today's inspection:

During review of children's files, LPA observed immunizations have not been transferred onto the blue immunization cards.

See 809D for deficiencies cited today. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
**Please see LIC 9102 for Advisory Notes.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with licensee Khadijeh Lashkar.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2023 11:48 AM - It Cannot Be Edited

Created By: Julia Placencia On 02/27/2023 at 11:19 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: LASHKARI, KHADIJEH & KHOSROW	FACILITY NUMBER: 434409641
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Licensee shall transfer children's immunization records onto blue immuzation cards and submit copies to LPA by due date of 3/10/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jason Jang

LICENSING EVALUATOR NAME:

Julia Placencia

LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

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