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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312655
Report Date: 08/02/2023
Date Signed: 08/02/2023 03:25:18 PM

Document Has Been Signed on 08/02/2023 03:25 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:FARSAI, ROYAFACILITY NUMBER:
304312655
ADMINISTRATOR:FARSAI, ROYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 509-4761
CITY:IRVINESTATE: CAZIP CODE:
92603
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
08/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Roya FarsaiTIME COMPLETED:
03:45 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analysts (LPA) Dean Thompson. LPA observed licensee Roya Farsai caring for 7 children inside the family room area. Licensee was operating within the licensed capacity as specified on license. Facility Day care hours are 8:00 AM - 5:30 PM, Monday through Friday.

A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions with the exception of Suraya Mir Khil. LPA observed Suraya Mir Khil inside the living room area of the home providing care and interacting with day care children present. Licensee stated Suraya Mir Khil has been working at the family child care home since May 2023.

LPA toured the inside and outside areas identified in the facility sketch as accessible to childcare children. At the time of arrival, LPA observed stairs leading to the second floor of the home was not fenced or barricaded. Off limits areas are made inaccessible by means of baby safety locks. The childcare area consists of family room, dining room, kitchen, and one bathroom. Licensee stated the children's primary area is the childcare room (family room).

The facility has a fireplace inside the family room that is inaccessible to children. There is a working carbon monoxide, smoke detector, and a fire extinguisher in the home that meet statutory and State Fire Marshall standards. During record review, Licensee was unable to provide proof showing a fire drill and disaster drills are being conducted at least once every six months. Licensee was reminded a fire/disaster drill needs to be conducted and documented at least once every six month.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FARSAI, ROYA
FACILITY NUMBER: 304312655
VISIT DATE: 08/02/2023
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In the areas that were evaluated, two Type A and four Type B deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. Facility Administration - Type A: 102370(d), Physical Plant - Type A: 102417(g)(3), Physical Plant - Type B: 102417(g)(9)(A), Facility Administration - Type B: 1596.8662(b)(1), Records - Type B: 1597.622(a)(1), and Records - Type B: 102418(a).

LPA Dean Thompson informed licensee Roya Farsai that this report dated 8/2/2023 document(s) Two Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Dean Thompson informed the licensee Roya Farsai to provide a copy of this licensing report dated 8/2/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.


Exit interview conducted and report was reviewed with the licensee Roya Farsai. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

During the exit interview, the LICENSEE Roya Farsai, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FARSAI, ROYA
FACILITY NUMBER: 304312655
VISIT DATE: 08/02/2023
NARRATIVE
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CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

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.

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: https://www.ada.gov/resources/child-care-centers/.



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

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Licensee was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FARSAI, ROYA
FACILITY NUMBER: 304312655
VISIT DATE: 08/02/2023
NARRATIVE
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Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections.

The home has age-appropriate toys for the ages served. LPA verified there is a working telephone service (home service). Licensee stated, they use the back yard for outdoor play, LPA inspected the back yard, and it was found to be incompliance. There are no bodies of water at the facility.

Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be in compliance. During children file reviews, LPA observed 4 out of 7 children were missing immunization records. LPA provided a copy of LIC 9227 Individual Infant Sleeping Plan and napping log and reviewed it with licensee.

The licensee Pediatric CPR/First Aid certification expires 8/7/2023. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee reviewed and within compliance. During file reviews, LPA observed assistant (S1) did not have copies of their immunization records inside their file. S1 could not provide proof of immunization records at the time of visit.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. Licensee and assistant was unable to provide proof of their mandated reporter certifications.

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/02/2023 03:25 PM - It Cannot Be Edited


Created By: Dean Thompson On 08/02/2023 at 02:07 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FARSAI, ROYA
FACILITY NUMBER: 304312655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(3)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above. At the time of arrival, LPA observed stairs leading to the second floor of the home was not fenced or barricaded which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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LPA observed licensee place a gate at the bottom of the staircase during visit.
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed Suraya Mir Khil inside the living room are of the home providing care and interacting with day care children present. Licensee stated Suraya Mir Khil has been working at the day care since May 2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Licensee stated she will have Suraya Mir Khil submit fingerprint documents.
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:Judy Hanson
LICENSING EVALUATOR NAME:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 08/02/2023 03:25 PM - It Cannot Be Edited


Created By: Dean Thompson On 08/02/2023 at 02:07 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FARSAI, ROYA
FACILITY NUMBER: 304312655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. During record review, Licensee was unable to provide proof showing a fire drill and disaster drills are being conducted at least once every six months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee stated a fire/disaster drill will be conducted and documented by POC due date. Proof will be sent to LPA
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee and assistant was unable to provide proof of their mandated reporter certifications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee stated proof will be sent to LPA by POC due date.
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:Judy Hanson
LICENSING EVALUATOR NAME:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/02/2023 03:25 PM - It Cannot Be Edited


Created By: Dean Thompson On 08/02/2023 at 02:07 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FARSAI, ROYA
FACILITY NUMBER: 304312655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above. During file reviews, LPA observed assistant (S1) did not have copies of their immunization records inside the file. S1 could not provide proof of immunization records at the time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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2
3
4
Licensee stated proof of immunization records for assistant will be submitted by POC due date.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above. During children file reviews, LPA observed 4 out of 7 children were missing immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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2
3
4
Licensee stated immunization for 4 children will be submitted by POC due date.
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:Judy Hanson
LICENSING EVALUATOR NAME:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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