Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191210523
Report Date: 12/15/2017
Date Signed: 12/15/2017 04:02:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME:MOZAFARI FAMILY DAY CAREFACILITY NUMBER:
191210523
ADMINISTRATOR:MOZAFARI, ZOHREHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 344-4740
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY:12CENSUS: 5DATE:
12/15/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Zohreh MozafariTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marina Pilossian conducted an unannounced Required 3 year visit. There were 4 infants and 1 preschool children present at the time of the visit. LPA observed licensee and her spouse in the home during the visit. LPA did not observe any pets in the home except for the fish in a bowl on the dining table.

The licensee's home is a single story 2 bedroom, 1 bathroom, living room, dining room, kitchen, converted garage into a third bedroom (per licensee the bedroom has no permit), back yard, laundry area outside and a shed. There is no pool, spa or other bodies of water on the premises. Family members residing in the home include two adults ( licensee, and her spouse).

Main care is provided in the living room, dining area, and the first bedroom located in the hallway to the right. Off limit areas include the master bedroom in the hallway, the converted garage into a bedroom located by the living/dining room area, the laundry area that is located in the back yard, and the shed. Children utilize the only bathroom in the home that is located in the hallway. LPA observed electric out let covers missing in the living room, bathroom and other areas of the house. LPA observed exersaucers outside in the yard. Per licensee she did not know that it is not allowed to be used for the day care children. LPA observed Child #1 playing in the living room with a toy (toy walker for the younger children to help them walk) while holding on to it, LPA observed licensee's spouse kick really hard on to the toy while child #1 was still holding on to it. LPA observed child #1 started to cry. Child #1 was intimidated. Licensee's spouse stated in his native language Farsi " the child rolled over his foot with the toy how many times". Licensee stated to LPA "children have to learn how to play with the toy". After some time while the children were sitting in the living room at the small table eating lunch, licensee was still in the kitchen bringing more food out for the rest of the children. LPA observed licensee's spouse sitting on the large sofa by child #3. Child #3 was sitting on the yellow small chair and eating lunch. LPA observed child #3 fall face down while on the chair and clearly child #3 was not being supervised. LPA observed child #3 crying with food in her mouth and licensee's spouse did not pick up the child, and waited for the licensee (wife) to pick up the child.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (310)337-4341
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (310) 337-4340
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2017
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230

FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2017
Section Cited
CCR
102423(a)(2)
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Personal Rights: Each child shall be accorded safe, healthful and comfortable accommodations, furnishing and equipment.

LPA observed child #1playing in the living room with a toy (toy walker for the younger children to help them walk).
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Licensee agrees to submit a statement explaining how the children will be accorded safe, healthful and comfortable accommodations at all times. The licensee will ensure that no child will be intimidated by any adult in the home. The statement is to be submitted by 12/22/17.
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LPA observed licensee's spouse kick really hard on to the toy while child #1 was still holding on to it. Child #1 was intimidated by the licensee's spouse. Child started to cry.
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Type A
12/15/2017
Section Cited
CCR
102423(a)(2)
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Personal Rights: Each child shall be accorded safe, healthful and comfortable accommodations, furnishing and equipment.

Child #3 was sitting on the yellow small chair and eating lunch. LPA observed child #3 fall face down while on the chair with food in
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Licensee agrees to submit a statement explaining how the children will be accorded safe, healthful and comfortable accommodations at all times. The licensee will ensure that no child will be left unsupervised. The statement is to be submitted by 12/22/17.
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her mouth, and clearly child #3 was not
being supervised. LPA observed child #3 crying with food in her mouth and licensee's spouse did not pick up the child, and waited for the licensee (wife) to pick up the child.

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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: Sharalyn Jenkins-SweetenTELEPHONE: (310)337-4341
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (310) 337-4340
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2017
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Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230

FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/25/2017
Section Cited
CCR
102417(9)
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Operation of a Family Child Care Home- An Emergency Disaster Plan was not observed on the wall. There shall be a written disaster plan per Title 22 and the Health and Safety Code Section 1596.841. The children are at potential risk in case of an emergency if the phone numbers are
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Licensee to update and post Emergency Disaster Plan and provide the proof to Community Care Licensing by 12/25/17, LPA printed a blank copy and provided to licensee.
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not immediately accessible.
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Type B
12/25/2017
Section Cited
CCR
102417g9A1
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Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill.
During LPA's visit, licensee was unable to produce a fire and disaster drill log documenting drills conducted once every six months.
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Licensee will conduct a fire and disaster drill and document the date and time the drill was conducted no later than 12/25/17
POC visit will be conducted.
Type B
12/25/2017
Section Cited
CCR
102418(g)
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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
LPA reviewed children's files and observed missing Immunization record for child #3.
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Licensee indicated the child has been immunized; however, the parents have not brought the immunization record to the facility. Licensee will request the parent to submit immunization records for the child. POC due date 12/25/17 submit a copy to the department.
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: Sharalyn Jenkins-SweetenTELEPHONE: (310)337-4341
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (310) 337-4340
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2017
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230

FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2017
Section Cited
CCR
102417(g)(4)
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Operation of a Family Child Care Home. Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger to children shall be stored where they are inaccessible to children.
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Licensee states she will place the safety latches. Effective immediately, licensee agrees to remove the hazardous items until the latches are replaced. Licensee to submit a statement to Community Care Licensing indicating when the latches are placed. POC due date 12/17/17.
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LPA observed cleaning chemicals and knives accessible in the kitchen drawers and under the sink and in the bathroom floor.
Licensee did not have safety latches in place making the chemicals, sharp objects accessible to the children.
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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: Sharalyn Jenkins-SweetenTELEPHONE: (310)337-4341
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (310) 337-4340
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2017
LIC809 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230

FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/25/2017
Section Cited
HSC
1597.622
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Employees or volunteers at family day care home; immunization requirements; records; exemptions: 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.
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The licensee shall ensure all employees or volunteers at the family day care home , have been immunized against influenza, pertussis, and measles. For those choosing to waive the influenza vaccine, proper documentation must be on file. The licensee mus mail proof of immunization no later
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Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
Per the licensee, she does not have her and spouse immunization's against influenza, pertussis and measles.
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than the close of business on 12/25/17 to the Department by mail.
Type B
12/25/2017
Section Cited
CCR
102417(g)(1)
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OPERATION OF A FAMILY DAY CARE - LPA observed electrical outlets uncovered in the living room area and the bathroom .
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The Licensee agrees to install outlet covers in all areas immediately . POC due date 12/25/17
Type B
12/25/2017
Section Cited
CCR
102417(g)(8)
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Operation of a Family Child Care Home: Licensee did not have a Facility Roster that included the ages of the children or their enrollment/last date in care. Facility roster was not updated.
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Licensee agrees to complete the roster Licensee agrees to maintain the roster and keep it up to date. Roster will be kept in an accessible location.
Submit a copy to the Department no later than 12/25/17
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: Sharalyn Jenkins-SweetenTELEPHONE: (310)337-4341
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (310) 337-4340
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2017
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230

FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/25/2017
Section Cited
CCR
102419(b)
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Parents Rights. The Licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in an accessible area in the family child care home at all times children are in care. LPA did not observe the Parent's Rights poster to be posted in a prominent area of the home.
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Licensee will ensure the Parent's Rights poster is posted in a prominent area of the home immediately and will submit proof to the Dept. POC visit will be conducted. Parent's Rights Poster must be posted by 12/25/17.
Type B
12/22/2017
Section Cited
HSC
1596.8555
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At the time of the visit LPA did not observed License posted.
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According to Licensee, she never knew that she had to post her license on the wall. Licensee will ensure to post the license on the wall. POC 12/22/17
Type B
12/25/2017
Section Cited
CCR
102417(g)
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OPERATION OF A FAMILY CHILD CARE HOME: The home shall provide safe toys, play equipment and materials.
LPA observed broken toys in the back yard.
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Licensee will remove broken play equipment from the backyard by 12/25/17 but agrees to not allow children to play in the back yard until all broken toys and equipment are removed. POC 12/25/17
Type B
12/25/2017
Section Cited
CCR
102417(g)(10)
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Operation of a Family Child Care Home. A baby exersaucers are not permitted on the premises of a family child care home
At the time of the visit LPA observed an exersaucer in the back yard.
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Licensee shall ensure that the baby exersaucers are removed from the premises by the close of business on 12/15/17 and submit a statement stating that the baby exersaucers have been removed and is not longer on the premises. POC due date 12/25/17.
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: Sharalyn Jenkins-SweetenTELEPHONE: (310)337-4341
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (310) 337-4340
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2017
LIC809 (FAS) - (06/04)
Page: 9 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
VISIT DATE: 12/15/2017
NARRATIVE
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The main entry door will be used to enter the facility; The home was found to be clean and orderly with proper ventilation for safety and comfort. The bathroom utilized by the children was inspected for inaccessibility of chemicals/toxins and other potential hazards to children in care. LPA observed Lysol toilet bowl cleaner placed on the floor right behind the toilet accessible to the children. The kitchen cabinets and drawers were inspected for inaccessibility of toxins/chemicals, knives and other sharp objects which may be harmful to children in care. LPA observed chemicals (Lysol, Pine Sol, 409, Clorox, Windex Pledge) and other chemicals under the kitchen sink. LPA observed sharp objects (scissors ) in the kitchen drawer accessible to the children. LPA did not observe any safety latches on the kitchen drawers or under the sink.

The Fire Extinguishers (2A-10-BC) was mounted on the wall outside in the yard. There are working smoke/carbon monoxide detectors located in the living room, and the kitchen. Per licensees, there are no weapons or firearms of any kind in the facility at this time. The LPA did not observe any weapons. LPA did not observe an updated fire drill log. Per licensee she does not have the log available to provide the LPA. LPA explained to the licensee fire drills are done every month. LPA observed Licensee's current Pediatric CPR (Adult/Infant /Child) and Pediatric First Aid certifications ( expire 06/2019).

LPA toured the backyard and found it to be fully fenced.

Licensee did not have the following documents posted in the FCCH; Facility License (LIC 203), Emergency Disaster Plan (LIC610a), Notification of Parents' Rights Poster (PUB 394), and Facility Roster ( LIC9040, included the ages of the children or their enrollment/last date in care). Licensee was not able to provide copies of immunization for herself and her husband. Per licensee, she does not have her immunization records pertussis, measles, and influenza. Licensee did not know she needed the immunization's.

A review of the children's records was conducted and are found to have the following: LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization. Licensee missing child #3 immunization record.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (310)337-4341
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (310) 337-4340
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2017
LIC809 (FAS) - (06/04)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
VISIT DATE: 12/15/2017
NARRATIVE
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The following was thoroughly discussed with the licensee:

Assembly Bill 633: Upon receipt by the licensee, licensees are to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this family child care home in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license. Copies of any of the above licensing documents the licensee has received in the prior 12 months shall be provided to parents/guardians of newly enrolled child at the facility.

Senate Bill 792: This bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles. Per the licensee, staff immunization are not up to date.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment

New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint. Update on Incidental Medical Services:

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

SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (310)337-4341
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (310) 337-4340
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2017
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
VISIT DATE: 12/15/2017
NARRATIVE
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The licensee was informed of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541

Email Address: childcareadvocatesprogram@dss.ca.gov

LPA Printed Acknowledgement of Receipt of Licensing reports (LIC9224) and provided to the licensee. Appeal rights were printed and provided.

Licensee is required to attend family child care orientation. LPA observed licensee call the Culver City Child Care Office and secure a family child care orientation on 01/16/2018 at 8:00am. Licensee to submit a copy of the certificate to the department.




Exit interview was conducted and a copy of the report was provided
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (310)337-4341
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (310) 337-4340
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2017
LIC809 (FAS) - (06/04)
Page: 4 of 9