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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 574500919
Report Date: 08/30/2023
Date Signed: 08/30/2023 11:29:52 AM

Document Has Been Signed on 08/30/2023 11:29 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KARIMI, SAFAFACILITY NUMBER:
574500919
ADMINISTRATOR:KARIMI, SAFAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 995-6673
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
08/30/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Safa KarimiTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Tjhia met with Licensee, Safa Karimi for the purpose of conducting a change of location inspection. Licensee is requesting a change of location from old facility with license #574500625 to current location.

All adults living and working in the facility have a criminal record clearances. 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.

The facility is a one story home that consists of 3 bedrooms, and 2 bathrooms. LPA and Licensee toured the entire home inside and outside. Off limit areas consist all bedrooms, garage, backyard and sheds.. Licensee acknowledged that children are never allowed in the off limit areas. Off limit areas will remain inaccessible by door handle covers, locked closed doors and supervision. Licensee understands that 100% supervision is required when children play any unfenced areas outside.

LPA discussed licensing requirements with Licensee including the posting of licensing inspection notices and reports, as well as injury and incident reporting. Fire extinguisher type 3A40BC located next to the main entrance door and first aid kit is located in upper left cabinet in the kitchen. Smoke alarm and carbon monoxide detectors were observed to be in operational order. Licensee stated there are no weapons in the home. There are no bodies of water on the property.

Hazardous items and personal hygiene items are made inaccessible to children. Sharp utensils are stored in location inaccessible for children. Licensee has a current Mandated Reporter Training Certificate. Current pediatric CPR and first aid training was verified and expires 09/2024. Report Continue on 809-C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KARIMI, SAFA
FACILITY NUMBER: 574500919
VISIT DATE: 08/30/2023
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LPA discussed new safe sleep regulations 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 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.

In addition, LPA discussed the infant sleep regulations with licensee. LPA discussed the requirement to check and log infant napping every 15 minutes for infants 24 months and under. LPA provided a copy of LIC 9227 Individual Sleeping Plan, for infants under 12 months, for licensee during today's inspection.

Licensee understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. Applicant understands that if an unusual incident occurs; 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 7 days to remain in compliance. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction



Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at
https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the licensee [or facility representative] (include name). Records, postings and reporting requirements were discussed. Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

As of today, Licensee will be approved for a Large Family Child Care Home to serve 12 children (when there is an assistant present) with no more than 4 infants or capacity of 14 children when 1 child in kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of 2 years old.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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