Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191210523
Report Date: 08/14/2018
Date Signed: 08/14/2018 11:33:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
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: 0DATE:
08/14/2018
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Zohreh MozafariTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Marina Pilossian conducted an annual Required inspection. LPA met with licensee. At 10:30am, LPA and licensee toured the facility indoor and outdoor. There were no children present at the facility. LPA observed licensee and her spouse in the home.

The facility is a one story home with 2 bedrooms, 1 bathroom, kitchen, dining area, and a living room, and an attached garage that is converted into a bedroom. Outdoor play of children is conducted in the back yard which is well fenced and was free of hazardous material. Child care is mainly conducted in the living room and the two bedrooms to the right of the living room (bedroom #1 and #2). The following are the off limit areas: the attached garage that is converted into a bedroom will be off limit to the children. LPA observed a working smoke detector, fully charged 2A10BC fire extinguisher and a working telephone.

There was good lighting and ventilation at the facility as well. All electrical outlets were covered with plastic covers. All detergents, cleaning supplies are stored in well latched cabinets. Sharp objects, including knives are stored in the kitchen and were inaccessible to children. Medications are stored away from children’s reach. LPA inspected the bathroom utilized by children and it was clean and orderly. Per the licensee, there are no firearms on the premises. LPA observed a well -stocked first aid kit, age appropriate indoor /outdoor toys for the children. Licensee has current CPR, first aid which expires in 6/2019. There are no bodies of water or pets at the facility. LPA observed that all necessary postings were visible.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2018
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
VISIT DATE: 08/14/2018
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LPA reviewed sample of children’s records and they were in order. All records contained correct forms: LIC 627 (Emergency Consent), LIC 700 (ID & Emergency), LIC 702 (Health History), LIC 613A (Personal Rights), LIC 995A (Parent's Rights), LIC 995E (Important Information for Parents), LIC 282 (Affidavit Liability Insurance).

The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Licensee states there are no firearms or weapons of any kind in the facility at this time. The First Aid kit was observed and complete.

LPA Pilossian toured the outdoor area. Children will utilize the back yard to play. The back yard is fully fenced. The front yard is not fenced, children will not have access to the front yard. Licensee was instructed that while children are outside playing in the back yard, visual care and supervision is required at all times. LPA observed play structure outside with a slide. The slide was made out of metal. LPA explained to licensee that she cannot use the slide for the children when the slide gets warm or hot to the touch to avoid children getting burned or injured. Licensee understands and will comply. Licensee stated that she is not bringing the children outside to play when the weather is hot.

Licensee was informed that it is required by law to post the following in the facility:

● Emergency Disaster Plan (LIC 610A) - This must be posted in your home next to the telephone and


the Earthquake Preparedness Checklist (LIC 9148), must be attached to the LIC 610A and available
to the public.
● Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home
where all parents can see it
● Facility License, (LIC 203)-Your Family Child Care Home License must be posted in an area of the
home where it can be easily seen.
● Notice of Site Visit (LIC 9213) must remain posted for 30 days (during the hours that children are in
care) after each site visit by a licensing representative.
● Any licensing report documenting a type “A” citation must be posted for 30 days during the hours that children are in care.
● Any licensing report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2018
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
VISIT DATE: 08/14/2018
NARRATIVE
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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.

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

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.html

Licensee was made aware 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

No deficiencies were observed or cited during today's visit.

Exit interview was conducted with licensee and a copy of this report was printed and provided.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2018
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MOZAFARI FAMILY DAY CARE
FACILITY NUMBER: 191210523
VISIT DATE: 08/14/2018
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Employee records must be maintained by the applicant and shall contain the following: LIC9052/Employee Rights, LIC 9108 Mandated Reporter Form, An employment contract or application containing the following information: Employees Full Name, Date of Birth, Driver's License Number, Date of Employment, Documentation of Health and Safety Training, Duties of the employee. Licensee is reminded that records for employees as well as children must be maintained for 3 years after separation for the FCCH.

Mandatory Forms for the children’s files: (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 (Blue) Card). Requirements for fire drills, earthquake drills, and documentation for both. Role and responsibilities of being a mandated reporter were reviewed.

The licensee was advised how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov. Regulation prohibits the smoking of tobacco in a private residence licensed as a family child care home during the hours of operation. State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category.

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.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2018
LIC809 (FAS) - (06/04)
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