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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411430
Report Date: 05/31/2024
Date Signed: 05/31/2024 11:53:58 AM

Document Has Been Signed on 05/31/2024 11:53 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SAMADANI, FARIBAFACILITY NUMBER:
434411430
ADMINISTRATOR/
DIRECTOR:		SAMADANI, FARIBAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 450-3564
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 0DATE:
05/31/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Fariba SamadaniTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 05/31/2024 at 10:30am Licensing Program Analyst (LPA) Christina Uribe, met with licensee Fariba Samadani for an UNANNOUNCED ANNUAL INSPECTION. Present for the inspection were 0 daycare children. 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 and does not operate during the summer.

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 detector, 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: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SAMADANI, FARIBA
FACILITY NUMBER: 434411430
VISIT DATE: 05/31/2024
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The licensee completed the Health and Safety training, CPR/First Aid certification expires on 10/07/25. The licensee is in compliance with the immunization laws and has completed the mandated reporter training on 11/07/22. Licensee is reminded of their responsibility to renew CPR/First Aid and Mandated Reporter certificates every two years. The emergency drill log was reviewed. All required forms are posted and visible for public review.

Records: LPA Uribe reviewed 5 children’s files and personnel records. Licensee only cares for school-aged children and does not have the need to maintain Safe Sleep Regulations. There is a current roster available for review and copy obtained. The facility does not have liability insurance and Affidavit Regarding Liability Insurance forms (LIC 282) were reviewed.


Provider Information Notices (PINs) & Quarterly Updates: Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders, by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email notifications.
CCLD Inspection Process: 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.

Criminal Record Clearance: 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.

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

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

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SAMADANI, FARIBA
FACILITY NUMBER: 434411430
VISIT DATE: 05/31/2024
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MyChildCarePlan.org: 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.

Incidental Medical Services (IMS): This facility does provide Incidental Medical Services (IMS). LPA inspected storage of medications and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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/resources/child-care-centers/.

Megan’s Law: During the exit interview, the licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Unusual Incident/Student Injury Report: 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.

No deficiencies found during today's inspection. One Advisory Note issued:

  • Advisory Note (TV): Licensee's emergency drill log has not been updated and there has not been an emergency drill recorded in the last 6 months.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the licensee, Fariba Samadani.

Page 3 of 3 ***End of Report***

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

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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