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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700600
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:48:47 PM

Document Has Been Signed on 09/29/2022 12:48 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:MIRZAIAN FAMILY CHILD CAREFACILITY NUMBER:
197700600
ADMINISTRATOR:RENI MIRZAIANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(747) 221-2137
CITY:SANTA CLARITASTATE: CAZIP CODE:
91387
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Teni MirzaianTIME COMPLETED:
12:56 PM
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On 9/29/2022, Licensing Program Analyst (LPA) Isabel Ortega conducted an announced prelicensing inspection for the purpose of a large relocation Family Child Care Home(FCCH) of 14 FCCH. LPA was greeted by licensee who guided the LPA on a tour of the Family Child Care Home.

Licensee will operate Monday through Friday: from 6:00 a.m. – 6:00 p.m. and Saturday and Sunday from 8:00 a.m. to 6:00 p.m. The Licensee will continue to provide breakfast, snack, lunch, afternoon snack and dinner as needed. Licensee plans to continue to provide transportation services, licensee has auto insurance and valid California Driver’s license.



This is a two-story family home which consist of four-bedrooms, three bathrooms, a kitchen, dining room, sun room, living room, laundry room in the attached garage, shed maintained key locked. The dining room and living room will be the primary location in which care is provided (referred to as the “Day Care area”). Children will utilize the bathroom located down the hallway by the dinning room. All bedrooms will be off limits rooms and areas are key locked and child safety gates are observed at the bottom of the stairs preventing children accessing the remaining of the home.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600
VISIT DATE: 09/29/2022
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The back yard is divided in two sessions; the yard is gated and fence there is a shed utilized for storage in the second back yard maintained locked. The side yard will be utilized for outside play. The off-limit areas include all four bedrooms, kitchen, laundry room (maintained key locked),second back yard, and two restrooms.
The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and center air ventilation. The home has age appropriate toys, play equipment and materials. Licensee stores sharp knives in the kitchen in top drawer, medication is stored inaccessible to children. Cleaning supplies and chemicals are stored in the attached garage and maintained key locked. Licensee has a complete First Aid Kit in the home with a temperature thermometer, which is stored inaccessible to children. Children are provided with cots during nap time.

There are no bodies of water nor pools on the premises. Licensee was reminded about ensuring proper care and visual supervision at all times especially during nap time.



Went over Safe Sleep with licensee and provided copy of PIN with individual Infant sleeping plan (12 months). Also, 15 min log was discussed for up to 24-month infants.

The licensee’s Pediatric CPR/First Aid expires on 5/21/2024. The licensee had the required immunizations against pertussis (Tdap), measles (MMR), and tuberculosis (TB). The Mandated Reporter training was completed on 4/03/2022.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600
VISIT DATE: 09/29/2022
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LPA observed fire extinguisher (2A10BC) that meets the State Fire Marshal standards (reading in green serviced 5/15/2022). The smoke detector and carbon monoxide detector and they were found to be in operable condition (tested at 11:51 a.m.). Home has central air conditioning and heating. Per the licensee, there are no weapons or firearms in the home, nor did LPA observe any weapons or firearms during the inspection. Licensee understands Emergency Drills continue to be conducted every six months and documented.

Licensee has the parent board and other Licensing required forms by the kitchen area visible to parents.

The following was discussed with licensee:

Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter were reviewed; Licensee was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind in the family child care home.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600
VISIT DATE: 09/29/2022
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The Licensee was informed that all adults living in or having access to the home, or employees are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Central Index prior to having contact or working 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 analyst of any person who will be visiting regularly or for longer than one week. The Licensee was advised to utilize the Request for Live Scan Service form LIC9163 to have adults fingerprinted and associated to the home.
The Licensee was advised of the requirement 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. The applicant was informed to utilize the Unusual Incident Report/Injury Report form LIC624B when submitting the report to the department.
The Licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian and place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports (LIC 9224). If these requirements are not met civil penalties per violation will be assessed.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600
VISIT DATE: 09/29/2022
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Beginning on January 1, 2018, Assembly Bill 1207 (2015) requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Applicants must meet requirements as a precondition to licensure. New employees shall have 90 days from date of employment to complete training as required. The training may be conducted at the following website www.mandatedreporterca.com. This certificate is valid for two years. All Licensing reports are recommended to be kept on file for minimum three years.

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.


The licensee was advised it is her responsibility to visit the department's website to access licensing forms, Quarterly Updates and Provider Information Notices (PINs): www.ccld.ca.gov Child Care Advocates: To sign up for our Quarterly Updates and Provider Information Notices (PINs), please subscribe online: http://www.cdss.ca.gov/inforesources/Community-Care-Licensing/subscribeFire
Licensee has met Title 22 regulations; Fire clearance was granted 5/24/2022, therefore, a Large Family Child Care Home License capacity of 14 children has been granted effective today 9/29/2022.
An exit interview was conducted, and a copy of this report and appeal rights were provided to Licensee on this day.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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