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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409346
Report Date: 11/09/2022
Date Signed: 11/09/2022 01:53:36 PM

Document Has Been Signed on 11/09/2022 01:53 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:GHORBAN ASHRAFI, ZOHREHFACILITY NUMBER:
073409346
ADMINISTRATOR:GHORBAN ASHRAFI, ZOHREHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 250-5550
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
11/09/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Zohreh GhorbanTIME COMPLETED:
01:55 PM
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On 11/9/22 at 9:40 AM Licensing Program Analyst (LPA) Michelle Sutton conducted an announced Pre-licensing Inspection at Zohreh Ghorban Ashrafi home and met with Applicant, Zohreh who has applied for a Large Family Child Care Home with a capacity of 14 children. The home was toured to conduct a Health and Safety Inspection. Present during today’s inspection is applicant and applicant's spouse, who is also the assistant. The Child Care home plans to operate Monday-Friday from 7am-5pm. Living in the home is applicant and applicant's spouse.

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.

INDOOR SPACE: LPA toured the indoor space of the home. The home consists of living room, dining room, 4 bedrooms, 3 restrooms, laundry room, backyard and garage. IN-USE AREAS: Living room, dining room, kitchen, restroom 1, bedroom 1 and left side of backyard. OFF-LIMIT AREAS: Master bedroom, restroom 3, restroom 2, bedroom 2, bedroom 3, laundry room, garage and right side of backyard. LPA observed child proof gates for all the off-limit areas in the FCCH. OUTDOOR SPACE: LPA toured the outdoor area (backyard) and it was fully fenced. LPA observed a shed with a lock inaccessible to children. There are no water bodies in backyard. LPA observed a gate separating the right side of the backyard which is off-limits to children.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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 3
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: GHORBAN ASHRAFI, ZOHREH
FACILITY NUMBER: 073409346
VISIT DATE: 11/09/2022
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LPA observed: fully charged 2A10BC fire extinguisher, working smoke and carbon monoxide detector. Medicines, cleaning products, sharp objects are stored inaccessible to children in cabinets and drawers with latches. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare home. Applicant states that there are 1 cat and fish tank in the home. There are no arms and ammunition stored in the home.

Discipline policy was discussed, and Applicant stated she will use quiet time method and communication with children. Applicant understands that children's personal rights should not be violated and no corporal punishment. Isolation of sick children will be in the living room. Supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed.

LPA discussed the safe sleep regulations with applicant 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 applicant 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.

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

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: GHORBAN ASHRAFI, ZOHREH
FACILITY NUMBER: 073409346
VISIT DATE: 11/09/2022
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Exit interview conducted and report was reviewed with the applicant Zohreh Ghorban Ashrafi.

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted

Entrance Checklist was provided to the applicant.

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.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
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