434415968-1-19-2023-07-CC-JCRZ-CN9448-20230119174552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415968
Report Date: 01/19/2023
Date Signed: 01/19/2023 05:46:05 PM

Document Has Been Signed on 01/19/2023 05:46 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:	SHENAS, SHAHIN & FATHIZADEH, NINA		FACILITY NUMBER:	434415968
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 5	DATE:	01/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Nina Fathizadeh		TIME COMPLETED:	06:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Janette Cruz met with Nina Fathizadeh, Licensee, for an unannounced Required 1-year annual inspection. LPA explained the nature of the visit and was granted access to the home by the Licensee. LPA also observed one adult and five children (5 infants) in the home during today's inspection. Nina identified the adult in the home as her adult assistant, Ivonne Vanessa Tovar, and stated that Tovar only started working for her home on 1/11/23. LPA advised Nina that Tovar does not have criminal record clearance on file. Nina stated that Tovar has not yet been fingerprinted. LPA also observed the Licensee was operating out of ratio requirements during today's inspection. LPA provided Licensees with a copy of regulations and guidance on infant ratio requirements and advised that the small family child care home license can only have a maximum of four infants. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Nina stated that she has not done a fire/disaster drill within the past six months. Licensees currently have an active Child Care Liability Insurance. Licensees have the required vaccinations (MMR, Tdap, & flu opt-out). LPA reviewed Licensees' Mandated Reporter Training for Child Care Workers credential. LPA reviewed five children's files. LPA discussed the safe sleep regulations with the 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 the 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.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHENAS, SHAHIN & FATHIZADEH, NINA	FACILITY NUMBER: 434415968
	VISIT DATE: 01/19/2023

NARRATIVE

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LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Licensee states that a child will be isolated in the daycare room area of the home if necessary due to illness or communicable disease.

LPA observed the home is clean, orderly, and safe for the day care children. LPA also observed a barricaded fireplace. LPA observed no open face heater units inside the home. The Licensee has the living room, a day care room and a bathroom primarily used for day-care. Off limit areas in the home: master's bedroom and two bedrooms, dining room and attached garage. Off limit areas outside the home: The pool area. The backyard is fully fenced. There is a pool that is fully fenced within the back yard. The fence is least five feet high and is constructed so that the fence does not obscure the pool from view. The fence is made from a hard mesh material. The gate swings away from the pool, self-closes and has a self-latching device, located no more than six inches from the top of the gate.

LPA observed a fully charged 2A10BC fire extinguisher, working smoke/carbon monoxide detectors and a fenced backyard. The Licensee states that she does not have pets and weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. All poisons are stored in high cabinets and at the garage, inaccessible to children. The Licensee states that she does not administer medication to the day care children at this time.

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

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.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHENAS, SHAHIN & FATHIZADEH, NINA	FACILITY NUMBER: 434415968
	VISIT DATE: 01/19/2023

NARRATIVE

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Supervision of children was discussed with Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than eight children in the home at any time. Licensee states that she does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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.

LPA provided Licensee with website resources on managing food allergies at school and handling medical emergencies related to food allergies.

CDC Managing Food Allergies at School
https://www.cdc.gov/healthyschools/foodallergies/index.htm

American Academy of Pediatrics Healthy Children Medical Emergencies
https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/When-to-Call-Emergency-Medical-Services-EMS.aspx

Exit interview conducted and report was reviewed with the Licensee, Nina Fathizadeh. Deficiencies were cited during this inspection.

A Notice of Site was issued an must remain posted for 30 days.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/19/2023 05:46 PM - It Cannot Be Edited

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: SHENAS, SHAHIN & FATHIZADEH, NINA	FACILITY NUMBER: 434415968
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102370(d)

Criminal Record Clearance

(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview and record review, the licensee did not comply with the section cited above.Licensees did not obtain criminal record clearance for an adult present in the home, whom Licensee identified as her adult assistant which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2023
	Plan of Correction
1 2 3 4	The Licensee submitted a written statement to the Department on 01/19/23 indicating that she understands that all adult(s) must obtain the required criminal record and child abuse index clearances prior to working or residing in the home. Civil penalty of $500 assessed today (see LIC 421BG). The Licensee must provide copies of this report to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months per the AB633 requirements.

Type A

Section Cited

CCR

102416.5(b)(1)

Staffing Ratio and Capacity

(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (1) Four infants; or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA observed five infants present in the home during inspection which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2023
	Plan of Correction
1 2 3 4	Licensee shall submit a written plan acknowledging understanding and complying with ratio of no more than four infants at any given time within 24 hours by POC date 01/20/2023. Office visit at San Jose Regional Office may be scheduled with Licensees.

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: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/19/2023 05:46 PM - It Cannot Be Edited

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: SHENAS, SHAHIN & FATHIZADEH, NINA	FACILITY NUMBER: 434415968
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)1

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee stated she has not done a fire/disaster drill within the past six months. which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2023
	Plan of Correction
1 2 3 4	Licensee will submit a conduct a fire/disaster drill and submit proof of documentation by POC due date 02/02/2023

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: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/19/2023 05:46 PM - It Cannot Be Edited

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: SHENAS, SHAHIN & FATHIZADEH, NINA	FACILITY NUMBER: 434415968
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviews, the licensee did not comply with the section cited above. Licensee did not obtain a current Mandated Reporter Training Certificatewhich posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2023
	Plan of Correction
1 2 3 4	Licensee will renew and submit her Mandated Reporter Training Certificate to LPA by POC due date 2/02/23.

Type B

Section Cited

CCR

102419(d)

Admission Procedures and Parental and Authorized Representative's Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record reviews, the licensee did not comply with the section cited above.Licensee did not maintain records of LIC 995A Notification of Parent's Rights for the following children: C1, C2,C4 and C5, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2023
	Plan of Correction
1 2 3 4	Licensee will submit a completed LIC995A Notification of Parents Rights for C1, C2, C4 and C5 by POC due date.

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: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC809 (FAS) - (06/04)

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