197493095-2-6-2025-12-CC-IORA-DDMTEX-20250206134039

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197493095
Report Date: 02/06/2025
Date Signed: 02/06/2025 01:42:48 PM

Document Has Been Signed on 02/06/2025 01:42 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	NABIPOURKASMA FAMILY CHILD CARE		FACILITY NUMBER:	197493095
ADMINISTRATOR/ DIRECTOR:	NABIPOURKASMA, SAREH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 360-7755
CITY:	NEWHALL	STATE: CA	ZIP CODE:	91321
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 3	DATE:	02/06/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Sareh Nabipour, Licensee		TIME VISIT/ INSPECTION COMPLETED:	01:45 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 1/22/2025 Licensing Program Analyst (LPA) Isabel Ortega conducted an unannounced Annual Random inspection. The LPA disclosed the purpose of the inspection and was granted entry, LPA toured the home. Upon entry to the home LPAt observed three children in care and one staff providing care and supervision..

The operational childcare hours are Monday through Thursday from 7:00 a.m. to 5:00 p.m.

Licensee provides children enrolled with breakfast, morning snack, lunch, and afternoon snack.

The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. The knives, medication, cleaning supplies and chemicals are kept inaccessible to children.

According to Licensee, there are no bodies of water on the premises. LPA did not observe any bodies of water during this inspection. According to licensee there are no weapons nor guns at the facility. LPA did not observe any weapons or guns at the facility during inspection.

There are educational age-appropriate toys and equipment on the premises.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

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 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: NABIPOURKASMA FAMILY CHILD CARE	FACILITY NUMBER: 197493095
	VISIT DATE: 02/06/2025

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

This is a one story family home with an attached garage, there is a living room, dining room, kitchen, four bedrooms, two restrooms, laundry area, one shed in the back yard and a back yard for outdoor play. Main care is provided in the dinning room and room #1(activities and nap time) room is referred to as the play area. Children utilize the restroom down the hall next to the play room. The children are provided with mats, and infants are provided with playpens, for napping(door remains open during nap). The off-limits areas are the three bedrooms #2, #3, #4, the laundry area, living room, attached garage (converted ADU), one shed maintained locked and utilized for personal storage.

The First Aid kit with a temperature thermometer was observed and complete. The required fire extinguisher (2A10BC) is reading in green (purchased once a year). Smoke and carbon monoxide detector are in operating condition. Fire and disaster drills are conducted every six months last drill was documented on 1/16/2025 at 10:00 a.m.

Licensee had all the required posted documents: Facility License (LIC 203, Notice of Parent's Rights Poster (PUB 394), Emergency Disaster Plan (LIC 610A), and Earthquake Preparedness Checklist (LIC 9148).

The licensee maintains proof of immunization against pertussis (TDAP), measles (MMR), Tuberculous (TB) and influenza.

Licensee provided certificate of completion Pediatric First Aid and CPR training which does not expire until 1/10/2027.

Childcare Provider Mandated Reporter training – General, Childcare Provider and Exam are required to be renewed every two-years. Childcare Provider Mandated Reporter certificate is dated 05/02/2023.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

Page: 2 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: NABIPOURKASMA FAMILY CHILD CARE	FACILITY NUMBER: 197493095
	VISIT DATE: 02/06/2025

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

The following were discussed: No smoking, infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category are permitted in the facility. The LPA also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files and posting requirements and penalty.

The licensee is aware all adults living in or having access to the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analysis of any person who will be visiting regularly or for longer than one week.

The Licensee was reminded to report Unusual Incidents. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. Licensee was informed to utilize the Unusual Incident Report/Injury Report form LIC624B when submitting the report to the department.

Licensee was not able to demonstrate a completed LIC9227 for infant birth to 1 year of age. A type B citation will be issued today. Licensee was not able to provided any sleep logs for the 2 of 2 infants enrolled in care. The safe sleep logs demonstrated to LPA by Licensee were blank. According to Licensee she did not have any records but maintained the form but was not able to get around to complete forms. A type B citation will be issued.

The following was also discussed with the licensee:
1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

Page: 3 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: NABIPOURKASMA FAMILY CHILD CARE	FACILITY NUMBER: 197493095
	VISIT DATE: 02/06/2025

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

2. Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.
3. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com
4. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be evaluated.

7. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

Page: 4 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: NABIPOURKASMA FAMILY CHILD CARE	FACILITY NUMBER: 197493095
	VISIT DATE: 02/06/2025

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

12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

13. Immunization Requirement: H&S 1597.622: 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. The licensee and all adults working with children have proof of immunization.

14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

16. Isolation for children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Childcare Home).

17. Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No baby bouncers, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

Page: 5 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: NABIPOURKASMA FAMILY CHILD CARE	FACILITY NUMBER: 197493095
	VISIT DATE: 02/06/2025

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

If you have any questions regarding the process or CARE tools, please send email inquiries 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/inspection-process.

Safe Sleep regulations (under 24 months) were discussed with Licensee and referred to the CCL web site for additional information and PINS. Infants under 2 years of age shall have the 15-minute checks logs completed during nap time. All infants under one year of age shall have the LIC9227 sleep plan completed by parent until infant master’s developmental stage of rolling over on their own. Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensees 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 22-02CCP. 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 Childcare Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

MyChildCarePlan.org-Family Childcare Homes Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

Page: 6 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: NABIPOURKASMA FAMILY CHILD CARE	FACILITY NUMBER: 197493095
	VISIT DATE: 02/06/2025

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

Megan’s Law - Family Childcare Homes During the exit interview, according to licensee there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Childcare Advocates:

To sign up for our Quarterly Updates please email the Childcare Advocates at chilcareadvocatesprogram@dss.ca.gov & (916) 654-154.
The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot line at 1-800-540-4000.

The facility was no found to be complying per Title 22 regulations, two deficiencies will be cited today. Safe Sleep Regulations for Infants are not being implemented. and followed. Licensee was not able to provide safe sleep logs for 2 out of 2 infants birth to 2 years. Also Infant birth to one did not have the LIC9227 completed nor on file. An exit interview was conducted, a copy of this Report, a Notice of Site visit and Appeal rights were provided and discussed.

All licensing reports are recommended to keep for 3 years, and the Notice of Site visit is to be posted visible to parents for 30 day

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

Page: 7 of 8

Document Has Been Signed on 02/06/2025 01:42 PM - It Cannot Be Edited

Created By: Isabel Ortega On 02/06/2025 at 01:11 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: NABIPOURKASMA FAMILY CHILD CARE	FACILITY NUMBER: 197493095
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in] which poses a potential health, safety or personal rights risk to persons in care. Licensee was not able to demonstrate a completed LIC9227 for infant birth to 1 year of age.
	POC Due Date: 02/11/2025
	Plan of Correction
1 2 3 4	Licensee will provide LIC9227 to parent at the time of pick up and have parent complete form. Licensee shall email LIC9227 form to the Palmdale RO by specified date.

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, (interview, and record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. Licensee was not able to provided any sleep logs for the 2 of 2 infants enrolled in care. The safe sleep logs demonstrated to LPA by Licensee were blank.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	Licensee will provide safe sleep logs completed to the Palmdale Regional Office by specified date. by email or mail. The safe sleep logs shall contain at least two weeks worth of recording during nap time.

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:

Lady King

LICENSING EVALUATOR NAME:

Isabel Ortega

LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

Page: 8 of 8