073409227-3-23-2022-02-CC-MGUT-CCSS8Q-20220323133932

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073409227
Report Date: 03/23/2022
Date Signed: 03/23/2022 01:39:41 PM

Document Has Been Signed on 03/23/2022 01:39 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:	HOSSEINI, MITRA		FACILITY NUMBER:	073409227
ADMINISTRATOR:	HOSSEINI, MITRA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 666-9965
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	03/23/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Mitra Hosseini		TIME COMPLETED:	02:00 PM

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	On 03/23/22, Licensing Program Analyst (LPA) Melissa Guirit met with applicant Mitra Hosseini for an announced Change of Location/Prelicensing Inspection. Also present for this inspection was fingerprint cleared husband. Applicant states that the hours of operation will be 8:00 am to 5:30 pm Monday through Friday. Applicant will be submitting the COVID-19 Self-Assessment. A fire clearance was received on 2/11/22 from the ECC Fire Protection Fire Department. The home was toured for a Health and Safety Inspection. The home is two stories. The home consists of three bedrooms, three bathrooms, child care area in the front of the home, kitchen, living area, laundry room, garage, and backyard. The on limits that is part of the child care will be the child care area at the entrance of the home, kitchen, living room, backyard, and the downstairs bathroom. The remainder of the home which includes the entire upstairs area, garage, and laundry room will be off limits which will be made inaccessible by use of closed and/or locked doors, safety gates and visual supervision. Per applicant the kitchen and living room will only be used to take children either out to the backyard or to the bathroom. LPA reminded applicant that there must be supervision when a child uses the restroom and when going outside. The living room will be used as the isolation area for ill children. The fully fenced backyard will be used as the outdoor play area. There are age appropriate toys in the home. There is an underground pool that has a fence that is at least five feet tall to make it inaccessible to children in care. Per applicant, there are no firearms in the home. LPA did not observe any hazardous materials or toxins accessible to children today. The home is equipped with a working smoke detector and carbon monoxide detector. There is a working telephone in the home. The home has a fully charged 2A10BC fire extinguisher. Mitra has current CPR/First Aid which expires 06/2023. Applicant completed mandated reporter training which must renewed by 10/06/2023. Applicant is in compliance with required immunizations. A copy of the deed was provided to LPA for review. Required forms were reviewed with applicant. See 809-C for continuance.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Melissa Guirit
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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: HOSSEINI, MITRA	FACILITY NUMBER: 073409227
	VISIT DATE: 03/23/2022

NARRATIVE

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LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Home, children’s forms/records, facility forms/records, and information to be posted. LPA advised the applicant that the postings need to be in a place that is visible and accessible to the public. LPA reviewed the ratio and capacity of a small family child care home license. 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.

The applicant is reminded of the following: to review and follow COVID-19 guidelines, to report any injuries or unusual incidents, including COVID-19 exposures and positive results at the facility. The applicant is advised to review licensing regulations and guidelines, including the Provider Information Notices (PINs) on the website www.ccld.ca.gov and to sign up to receive quarterly updates by email by sending a request to ChildCareAdvocatesProgram@dss.ca.gov.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 verified that the applicant has a criminal record clearance and is associated to the license. Licensee was reminded of the responsibility as a mandated reporter. The licensee was reminded that the mandated reporter training needs to be renewed every 2 years, at www.mandatedreporterca.com.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Melissa Guirit
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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: HOSSEINI, MITRA	FACILITY NUMBER: 073409227
	VISIT DATE: 03/23/2022

NARRATIVE

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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.

This home will remain pending until April 1st, 2022. An exit interview was conducted with applicant and report provided to Mitra Hosseini. This report shall remain on file for 3 years.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Melissa Guirit
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

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