<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416390
Report Date: 08/10/2021
Date Signed: 08/10/2021 04:47:26 PM

Document Has Been Signed on 08/10/2021 04:47 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:ADELI, HAMIDEHFACILITY NUMBER:
434416390
ADMINISTRATOR:ADELI, HAMIDEHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 888-6847
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
08/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Hamideh AdeliTIME COMPLETED:
05:00 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
#2 Licensing Program Analyst (LPA), Marilou Monico, met with Licensee, Hamideh Adeli, for a Required - 1 Year inspection. Licensee's two adult helpers, licensee's husband, licensee's four-year-old daughter, and 11 daycare children including four (4) infants, seven (7) preschool age were also present. There are two (2) adults residing in the home: licensee and her husband. The daycare is a one storey, three-bedroom and one-bath house. The daycare is open Monday to Friday from 7:00 AM to 6:00 PM.

LPA toured the home inside and out with the Licensee. Off limit areas in the home: master bedroom and attached garage. Off limit areas outside the home: locked storage shed. LPA observed sufficient toys and play equipment for the day care children. Bathroom used by children was observed to be clean and in good condition. There were no bodies of water observed. Per Licensee, there are no weapons in the home. LPA observed a fully charged 3A40BC fire extinguisher, glass covered fireplace, functioning carbon monoxide and smoke detector, and fenced backyard. Cleaning compounds, detergents, sharp objects, and other similar items were stored inaccessible to children.

LPA discussed with Licensee Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years. Mandated Reporter Training can be accessed at www.mandatedreporterca.com. Licensee's Mandated Reporter Training (AB1207) expires on January 4, 2022. Licensee has current Pediatric CPR/First Aid certifications with an expiration date of October 18, 2022.

LPA reviewed four (4) children's files and two helper's files. Copy of children's roster was obtained. Fire/disaster drill was conducted on July 2, 2021.

Continuation on next page:
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2021
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 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: ADELI, HAMIDEH
FACILITY NUMBER: 434416390
VISIT DATE: 08/10/2021
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
26
27
28
29
30
31
32
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 reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

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.
LPA reviewed with Licensee and provided her a copy of Safe Sleep Regulations (PIN 20-24-CCP).

Incidental Medical Services (IMS) policy was discussed. Licensee stated that she's not planning to provide IMS at this time.

As a result of this inspection, deficiencies were cited on the following page:



A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/10/2021 04:47 PM - It Cannot Be Edited


Created By: Marilou Monico On 08/10/2021 at 04:08 PM
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: ADELI, HAMIDEH
FACILITY NUMBER: 434416390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited
HSC
1597.622(a)(1)

1
2
3
4
5
6
7
Employees or volunteers at family day care home; immunization requirements; records; exemptions: (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
1
2
3
4
5
6
7
Licensee states she will submit proof of immunization records for her two helpers by 09/24/21.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Helper #1 is missing immunization in measles, pertussis, and influenza. Helper #2 is missing immunization in measles and pertussis. This poses a potential risk to the health and safety of children in care.
8
9
10
11
12
13
14
Type B
09/24/2021
Section Cited
CCR102369(b)(9)

1
2
3
4
5
6
7
Application for Initial License - Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
1
2
3
4
5
6
7
Licensee states she will submit proof of TB test for her two helpers by 09/24/21.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Helpers #1 & 2 do not have TB test records in their files. This poses a potential risk to the health and safety of children in care.
8
9
10
11
12
13
14
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:Anthony Studebaker
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3