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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415598
Report Date: 03/21/2022
Date Signed: 03/22/2022 02:45:19 PM

Document Has Been Signed on 03/22/2022 02:45 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:NEINAVAEI, SHIMAFACILITY NUMBER:
434415598
ADMINISTRATOR:SHIMA NEINAVAEIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 627-1702
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
03/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:SHIMA NEINAVAEITIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ofelia Calivo met with Licensee Shima Neinavaei for an unannounced Required - 1 Year Inspection. LPA was granted access to the home by the Licensee and toured both indoor and outdoor areas during the inspection. Also present in the home were licensee's 12-year-old daughter, who was about to leave for school, and Licensee’s husband, Hamidreza Khosravi, and four (4) children. LPA observed all required posted materials. Hours of operation for the facility are Monday to Friday, 7:30am to 5:20pm. There are no active waivers or exceptions for this facility. Licensee states that there are three adults residing in the home: Licensee, her husband Hamidreza Khosravi, their son Amirali Khosravi, and their minor daughter.

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.

LPA reviewed facility roster (LIC 9040). Fire/disaster drill was last conducted on January 20, 2022. LPA observed a fully charged 3A40BC fire extinguisher and functioning smoke detector and carbon monoxide detector. Licensee states that she does not have children in care who require Incidental Medical Services and does not administer medication at this time. Licensee states that there are no weapons or firearms in the home.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Ofelia Calivo
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NEINAVAEI, SHIMA
FACILITY NUMBER: 434415598
VISIT DATE: 03/21/2022
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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 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

Indoor and outdoor areas of the facility were inspected today and observed to be clean and orderly. Off limit areas in the home: attached garage and master bedroom and bedroom #4. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the home via bottles and sippy cups. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 627-1702.

The outdoor licensed areas of the home were inspected and observed to be fenced in. Off limit area outside the home include: left side of the home and gated area of the backyard. LPA observed play equipment was in good condition and age-appropriate. There were no bodies of water observed.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page 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.

Four (4) children’s files were reviewed during today's inspection for the following records: Notification of Parents Rights (LIC 995A), Consent for Emergency Medical Treatment (LIC 627), Identification and Emergency Information (LIC 700), and Immunization Record.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Ofelia Calivo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: NEINAVAEI, SHIMA
FACILITY NUMBER: 434415598
VISIT DATE: 03/21/2022
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Licensee has a current Mandated Reporter Training which will expire on October 19, 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years, website: www.mandatedreporterca.com. Assembly Bill (AB) 633 was discussed with Licensee. Licensee has current Pediatric CPR/First Aid certification with an expiration date of October 2023.

LPA reviewed with Licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Adoptions of new laws, pay annual fees etc.

Supervision of children was discussed with the Licensee and she understands that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee Shima Neinavaei.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Ofelia Calivo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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