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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010207861
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:26:34 PM

Document Has Been Signed on 03/03/2022 02:26 PM - 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:KHADIVI, AZAMFACILITY NUMBER:
010207861
ADMINISTRATOR:KHADIVI, AZAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 444-4080
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 5DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Azam KhadiviTIME COMPLETED:
03:30 PM
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On 03/03/2022 at 12:41 AM Licensing Program Analyst (LPA), A. Curry arrived at the home and conducted an unannounced random inspection. LPA met with licensee, Azam Khadivi, who granted inspection authority to tour the facility. Also present for the inspection were licensee’s assistants, Nancy Vay, Chanty Khim, and 5 children in care, which consist of 4 infants and 1 preschool child. Licensee states there are currently 10 children enrolled. Children’s files were reviewed.

The home is two-stories, but only the downstairs area, which has a separate entrance, is used for daycare. The children use the entire downstairs which consist of 3 rooms, bathroom, kitchen, and backyard. The off-limits area is the entire upstairs, which will be inaccessible by closed and/or locked doors and visual supervision. The isolation area is in one of the rooms away from other children. The LPA toured all areas used by children.



Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There were no fireplaces or open face heaters accessible to children. There were safe toys, play equipment, and materials observed for children. There is a working telephone in the home. All poisons, cleaning solutions, medications, and other items that pose a danger to children are inaccessible during this visit. The licensee does understand that poisons must be in a locked cabinet/drawer or placed out of reach of children. The home is equipped with a fully charged 3A40BC fire extinguisher, working smoke alarm, and working carbon monoxide detector. Licensee stated there are no firearms on the premises. There are no pools, spas, hot tubs, fishponds or similar bodies of water. Licensee has current CPR and First Aid training which expires on October 19, 2023 respectively.

LPA observed and inspected sleeping equipment for infants. All equipment meets the US Consumer Product Safety Commission safety standards. LPA observed that cribs and/or play yards were free from loose articles and objects. There are no objects hanging above or attached to the side of the crib. Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months of age should be placed on their back for sleeping.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: KHADIVI, AZAM
FACILITY NUMBER: 010207861
VISIT DATE: 03/03/2022
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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.

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.

LPA discussed the safe sleep regulations with licensee 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed with the licensee Azam Khadivi

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC809 (FAS) - (06/04)
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