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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411430
Report Date: 11/03/2022
Date Signed: 11/03/2022 11:07:55 AM

Document Has Been Signed on 11/03/2022 11:07 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:SAMADANI, FARIBAFACILITY NUMBER:
434411430
ADMINISTRATOR:SAMADANI, FARIBAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 450-3564
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 0DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Fariba SamadaniTIME COMPLETED:
11:15 AM
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On 11/03/2022 at 9:30am Licensing Program Analyst (LPA) Christina Uribe, met with licensee Fariba Samadani for an UNANNOUNCED ANNUAL INSPECTION. Present for the inspection were 0 daycare children and 1 fingerprint cleared adult resident of home, and the licensee is within ratio today. Upon arrival LPA provided licensee a copy of the Entrance Checklist (LIC 126). The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday-Friday 2:30pm-6:00pm. The facility operates as an after school child care and hours of start time may vary depending on the school schedule.

The home is a single story home with 3 bedrooms, 2 bathrooms, living room, kitchen, dining area, garage and back yard. LPA observed the home to be neat and clean with central heating and ventilation for safety and comfort. All on/off-limit areas are consistent with the facility's pre-licensing reports.

The OFF-LIMIT AREAS are the two back bedrooms, primary bathroom, and the garage and are inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS are the kitchen, front bedroom, bathroom at end of the hall, living room, and backyard.

The facility’s outdoor play space is located in the backyard of the home. The fence is in safe condition free from hazards which could pose a risk to children in care. There is ample shade available and gates are locked at all times while children are in the yard.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, carbon monoxide, telephone and fully stocked first aid kit. There are no pools, hot tubs or any other bodies of water present at the time of the inspection. Per licensee, there are no firearms on the premises or pets in the home. There is a fireplace in the living room which is barricaded to prevent access to children in care.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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: SAMADANI, FARIBA
FACILITY NUMBER: 434411430
VISIT DATE: 11/03/2022
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The licensee completed the Health and Safety training, CPR/First Aid certification expires on 09/29/23. The licensee is in compliance with the immunization laws and has completed the mandated reporter general training on 07/28/21.

The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 08/10/22. All required forms are posted and visible for public review.

LPA Uribe reviewed 5 children’s files and personnel records. There is a current roster available for review. The facility does not have liability insurance and Affidavit Regarding Liability Insurance forms (LIC 282) were reviewed. Staff interview also conducted and documented.



Incidental Medical Services (IMS) policy was discussed and LPA reviewed medication, storage, and records for compliance. 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.

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.

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.

Effective August 1, 2003 California Law requires Child Care 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 to the regional office by phone and the written report, LIC 624, within 7 business days.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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: SAMADANI, FARIBA
FACILITY NUMBER: 434411430
VISIT DATE: 11/03/2022
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No deficiencies cited during today's inspection. Please see attached advisory note pages for technical violations issued today.
  • Technical Violation: Licensee needs to keep a copy of the Criminal Record Statement (LIC 508) form & proof of TB clearance for her adult nephew residing in the home.
  • Technical Violation: Licensee has a current mandated reporter certificate for the general training but must obtain a certificate for the Child Care Provider (AB 1207) training.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Fariba Samadani.

Page 3 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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