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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416007
Report Date: 07/20/2022
Date Signed: 07/20/2022 10:36:56 AM

Document Has Been Signed on 07/20/2022 10:36 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:NOURI, KOBRA & EBRAHIMI LOUYEH, HALEHFACILITY NUMBER:
434416007
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 4DATE:
07/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Haleh Ebrahimi Louyeh and Kobra NouriTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Janette Cruz, conducted a case management inspection in response to Licensee's request to increase the capacity from 8 to 14 children. LPA met with Haleh Ebrahimi Louyeh and Kobra Nouri, Licensees. LPA observed two infants and one preschool child present in the home. LPA also observed Kobra's spouse, Homayoun Ebrahimi Louyeh and Haleh's minor child present in the home. There are three adults residing in the home: Licensees and Licensee's spouse. The daycare is open Monday thru Friday from 7:30 AM to 5:30 PM. Licensees have current CPR/First Aid certifications and Mandated Reporter Training certificates on file. Both indoor and outdoor areas of the home were inspected.

LPA observed no fire place, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons and no pets in the facility. LPA observed a fully charged 2A10BC fire extinguisher. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored under kitchen sink (locked) and in a locked kitchen drawer. Backyard is fenced. Off limit areas: 2 bedrooms, one bathroom, garage, and left side yard. Sharp objects, medications, cleaning products are stored out of reach of children. LPA obtained a copy of children's roster. LPA reviewed staff and children's files.

A review of staff records during today's inspection indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-carelicensing/public-information-and-resources/safesleep as an additional resource. LPA also informed Applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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: NOURI, KOBRA & EBRAHIMI LOUYEH, HALEH
FACILITY NUMBER: 434416007
VISIT DATE: 07/20/2022
NARRATIVE
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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.

Fire clearance was granted on June 24, 2022. A license for a Large Family Chid Care Home will be granted upon review and approval by LPA's manager.

Exit interview was conducted with Haleh Ebrahimi Louyeh and Kobra Nouri, Licensees. As a result of this inspection, deficiencies were cited. See 809D.

A Notice of Site Visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2022 10:36 AM - It Cannot Be Edited


Created By: Janette Cruz On 07/20/2022 at 09:49 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: NOURI, KOBRA & EBRAHIMI LOUYEH, HALEH
FACILITY NUMBER: 434416007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2022
Section Cited
CCR
102425(c)(2)

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Infant Safe Sleep (c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file......

(2) The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.
This requirement was not met as evidenced by:
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Licensees will submit to LPA, Individual Infant Sleeping Plan for one infant in care by POC date.
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Based on observation, interviews and record reviews, Licensees did not comply with section cited above. Licensees did not maintain an Infant Sleeping Plan for one infant enrolled in care which poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/27/2022
Section Cited
CCR102425(j)(1)(D)

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Infant Safe sleep (j)(1)The provider shall physically check on the infant every 15 minutes.
(D)Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:
a. Date.
b. Infant’s name.
c. Time of each 15-minute check.
This requirement was not met as evidenced by:
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Licensees will submit to LPA, sleep checks documentation for one infant in care by POC date.
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Based on observation, interviews and record reviews, Licensee did not comply with section cited above. Licensees did not maintain a documentation of safe sleep checks for one infant enrolled in care which poses a potential health, safety or personal rights risks to persons in care.
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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
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


LIC809 (FAS) - (06/04)
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