<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409227
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:13:22 PM

Document Has Been Signed on 05/18/2023 03:13 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, MITRAFACILITY NUMBER:
073409227
ADMINISTRATOR:HOSSEINI, MITRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 666-9965
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 5DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Mitra HosseiniTIME COMPLETED:
04:00 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 05/18/2023 at 1:10 PM, Licensing Program Analyst (LPA) Christina Watts conducted an unannounced annual inspection for Mitra Hosseini's large family child care home. LPA met with licensee and guided analyst on a tour of the facility. During today's inspection, there were 5 children in care (2 preschoolers and 3 infants) and 6 children enrolled. Also present during inspection is an assistant who has Criminal Record Clearance. Family members residing in the home are licensee and licensee husband. All adults in home have Criminal Record Clearance. Facility hours of operations are Monday - Friday 7:00 AM - 6:00 PM.

This is a two story home which consists of 3 bedrooms, 2 1/2 bathrooms, kitchen/dining room, living room, family room, laundry room, attached garage, backyard with a swimming pool.
The children on limits areas: Living room, Family Room, Kitchen/Dining Room, First Floor Half bathroom and backyard.
Areas off limits include: Entire second floor which includes 3 bedrooms and 2 bathrooms, laundry room and attached garage.
The LPA toured all areas used by children during this visit.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and central heating system for safety and comfort. There were safe toys, play equipment and materials observed for children. There are stairs in the home that are made inaccessible for children in care. There is a working telephone in the home. Detergents, poisons, cleaning compounds, medications, and other items which can pose a danger to children are made inaccessible in the home. *CON'T ON PAGE 2*
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Christina Watts
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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 5
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: 05/18/2023
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
*PAGE 2*

Per licensee, there are no weapons or firearms in the home. Licensee has an up to code 2A10BC fire extinguisher and working smoke/carbon monoxide detector on the premises. LPA observed a electric fireplace in the family room that is made inaccessible to children in care. Licensee last conducted fire drill 03/2023. Licensee stated there is 1 dog in the facility.

LPA inspected the backyard and observed a fully fenced and safe backyard for children. LPA also observed age appropriate toys for children to play with. LPA observed a swimming pool and fence that is within Community Care Licensing regulations. Facility does not provide transportation for children, but understands that children cannot be left alone, unattended in parked vehicles.

Children’s records were reviewed to ensure that each child has an Identification and Emergency form. Licensee stated there Pediatric First Aid and CPR certificate will expired in June 2023 however is unable to provide LPA a copy of the certificate. Upon record review, it was discovered that Assistant has a current Pediatric/First Aid certificate that will expire in July 2023. LPA reminded licensee of the importance and requirement of having a current and up to date Pediatric CPR/First Aid certificate. Licensee stated she will enroll in the class and complete training. Upon completion of training, licensee stated she will submit a copy to licensing. Required postings were observed near the entrance.

LPA reminded licensee day care needs to be operated within the limitations and capacity of a Large Family Child Care Home with regards to ratios and that Licensee has to be present in the day care for 80% of the operation hours.


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.*CON'T ON PAGE 3*

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Christina Watts
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 05/18/2023
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
*PAGE 3*

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) Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

On or before March 30, 2018, any person who works in a child care facility shall complete Mandated Reporter training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers. Licensee has provided Mandated Reporter certificate and the certificate will expire 10/2023.


Licensee 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.

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

LPA Christina Watts informed Mitra Hosseini that this report dated 05/18/2023 documents a Type B citation. Type B citation(s) are a potential risk(s) to the health, safety, or personal rights of children in care.

Exit interview conducted and report was reviewed with the licensee, Mitra Hosseini. A notice of site visit was given and must remain posted for 30 consecutive days.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Christina Watts
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/18/2023 03:13 PM - It Cannot Be Edited


Created By: Christina Watts On 05/18/2023 at 02:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HOSSEINI, MITRA
FACILITY NUMBER: 073409227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above when licensee could not provide CPR/First Aid certificate while caring for 3 infants and 2 preschooler which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
1
2
3
4
Licensee will submit completed certificate and submit certificate to licensing.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Sherelle Johnson
LICENSING EVALUATOR NAME:Christina Watts
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5