574500506-10-12-2021-53-CC-SWIS-C7QPC3-20211012111117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 574500506
Report Date: 10/12/2021
Date Signed: 10/12/2021 11:11:27 AM

Document Has Been Signed on 10/12/2021 11:11 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	BAHRAMI, SELSELAH		FACILITY NUMBER:	574500506
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	10/12/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Selselah Bahrami		TIME COMPLETED:	11:00 AM

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	On October 12, 2021 Licensing Program Analyst (LPA) Stacey Williams met with Applicant, Selselah Bahrami for the purpose of a pre-licensing inspection for a change of location. Applicant was previously licensed with facility number 573622748. Licensee’s husband was present during the inspection. All adults in the home have received a criminal background clearance. Applicant owns the home and has provided a copy of the control of property. LPA toured the home inside and out with Applicant. LPA observed the required licensing posters throughout the home, including COVID-19 guidelines. The Applicant resides in a two story 5-bedroom 3.5-bathroom home which includes a living room, dining room, laundry room, office, and loft. Off limit areas will be: entire upstairs, kitchen, living room, downstairs half bathroom, laundry room, backyard and the garage. Applicant will take children to the park for outdoor time and will have 100 percent supervision while outside. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detector and a fire extinguisher were observed in the home all of which meet regulation standards. Pediatric CPR and first aid training was verified and expires- 12/2022. Applicant stated there are no weapons in the home. There are no bodies of water at the home. Applicant completed the required AB1207 Mandated Reporter training. Applicant understands the training must be completed once every two years and can be accessed at www.mandatedreporterca.com . *Report continued on 809-C*

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: BAHRAMI, SELSELAH	FACILITY NUMBER: 574500506
	VISIT DATE: 10/12/2021

NARRATIVE

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Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that if anyone else works with the children, they must also obtain the following: EMSA certification, CPR and first aid training, immunization for Measles, Pertussis and Influenza, TB clearance, and complete AB1207 Mandated Reporter Training.

Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

Applicant understands that the Family Childcare Home license is not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours. LPA explained to the Licensee that if she moves and would like to continue to provide care, she must submit a change of location application and have the new home inspected again.

Applicant understands that if an unusual incident occurs; Community Care Licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within seven days to remain in compliance.

Applicant understands that if any structural changes are made to the home; Community Care Licensing must be notified prior to construction. Licensee understands that if she o makes any off-limit areas an ON-limits for children, she must notify Community Care Licensing and LPA must do an inspection BEFORE children are allowed in the areas.

Applicant understands that children’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to three years. Licensee understands that their License, Emergency Disaster Plan, and the Parents Rights Poster must be posted in the home. Licensee will have the forms posted in the home.

Report continued on 809-C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: BAHRAMI, SELSELAH	FACILITY NUMBER: 574500506
	VISIT DATE: 10/12/2021

NARRATIVE

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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 (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

This facility evaluation report was reviewed and discussed with the Applicant. LPA encouraged Applicant to review the Department website at WWW.CCLD.CA.GOV for childcare updates, current forms, legislation and regulation information and updated COVID-19 guidance for childcare providers and programs. The implementation of AB 2370, lead exposure in Family Child Care Home, Safe Sleep regulations, and COVID- 19 guidelines for childcare providers was discussed.

Effective October 12, 2021, Applicant is approved for a for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

Exit interview conducted with Applicant, Selselah Bahrami.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC809 (FAS) - (06/04)

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