Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618345
Report Date: 07/12/2019
Date Signed: 07/12/2019 11:19:18 AM

COMPREHENSIVE INSPECTION
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:MAZLOOM, ZIBAFACILITY NUMBER:
343618345
ADMINISTRATOR:MAZLOOM, ZIBAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 990-4894
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:14CENSUS: 5DATE:
07/12/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Ziba MazloomTIME COMPLETED:
11:30 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
Licensing Program Analyst (LPA) Kelly Ferrara met with Licensee Ziba Mazloom for an unannounced random annual inspection of her large family child care home. All adults in the home have obtained a criminal record clearance. Hours of operation are Monday through Friday 8 AM- 6 PM. There were six children present at the time of inspection.

A health and safety inspection was conducted in all areas accessible to children. Off limit areas include: two front bedrooms, laundry room, and garage. Licensee stated that she would like to make her master bathroom on limits now based on wanting to use it for emergencies. LPA observed a working phone, 2A10BC fire extinguisher, fireplace that is screened, first aid kit, and functioning smoke and carbon monoxide detectors that meet regulations. LPA observed a fire drill log with the last drill conducted in July 2019. Licensee stated that she did not have a current children's roster. Knives, medications, and chemicals were all stored inaccessible to children. LPA did not observe any bodies of water on the premises. LPA observed the interior of the Licensee's gun safe and observed that ammunition and firearms were stored together. This is a zero tolerance, Type A violation.

LPA observed documentation for the Licensee. LPA observed that Mandated Reporter training had been completed and LPA advised that this must be done every two years. LPA observed a current CPR/First Aid certificate that expires in January 2020. Licensee was not able to provide proof of her immunizations to MMR and Pertussis and LPA verified that the documentation was not in the Regional Office file. All children's files were reviewed and LPA observed that six out of six files did not contain the Medical Consent form (LIC 627) and four out of six files did not contain the Notification of Parent's Rights (LIC 995A).

Continued page 2
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5935
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2019
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 4
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: MAZLOOM, ZIBA
FACILITY NUMBER: 343618345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2019
Section Cited

1
2
3
4
5
6
7
Child's Records (a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).(1)The licensee shall keep the signed and dated notice form for at least three years following termination of service to the child. This requirement was not met as evidenced by: LPA observed four out of six
8
9
10
11
12
13
14
files did not have the Notification of Parent's Rights (LIC995A) and six out of six files did not have the Medical Consent form (LIC 627). This poses a potential health and safety risk to the children in care.
8
9
10
11
12
13
14
Type B
08/12/2019
Section Cited

1
2
3
4
5
6
7
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841 Each child day care facility shall maintain a current roster of children who are provided care in the facility. This requirement was not met as evidenced by: Licensee did not have a children's roster available for review.
Type B
08/12/2019
Section Cited

1
2
3
4
5
6
7
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. This is requirement was not met as evidenced by: The Licensee was not able to provide proof of immunizations for herself. This is a potential health and safety risk.
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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: MAZLOOM, ZIBA
FACILITY NUMBER: 343618345
VISIT DATE: 07/12/2019
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
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.

The facility evaluation report was reviewed and discussed with the Licensee. Notice of site visit was provided and it must remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of 3 years for public review upon request. Safe sleep information was given to the Licensee.

See 809D for deficiencies cited based on today's inspection. One Type A Title 22 deficiency is cited on the subsequent page. Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, Director shall post LIC 809-D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5935
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: MAZLOOM, ZIBA
FACILITY NUMBER: 343618345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/15/2019
Section Cited

1
2
3
4
5
6
7
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:.... (4)(C) Ammunition shall be stored and locked separately from firearms.
This requirement was not met as evidenced by: LPA observed the interior of the Licensee's gun safe. LPA observed multiple
8
9
10
11
12
13
14
boxes of ammunition were stored in the gun safe with the firearms. This poses an immediate health and safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4