304313946-12-21-2021-06-CC-KDEI-C9WVTD-20211221154259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313946
Report Date: 12/21/2021
Date Signed: 12/21/2021 03:43:18 PM

Document Has Been Signed on 12/21/2021 03:43 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	AZARI, NASRIN		FACILITY NUMBER:	304313946
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	12/21/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Applicant Ms. Azari, Nasrin		TIME 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	Licensing Program Analyst (LPA) Desai, Ketki conducted an announced in-person Pre-Licensing inspection for a new Small Family Child Care home. LPA met with the applicant Ms.Azari, Nasrin and the adult member who provided a tour of the new home. A review of the Facility Personnel Report Summary indicates adult residents, who require caregiver background check clearances, transfers, exemptions have been obtained and they are cleared. Applicant stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. Applicant was reminded if changes, to notify the licensing office. The applicant is requesting a Small family childcare home license. Per applicant, operation hours will be Monday to Friday 6:30 AM to 6:30 PM and care and supervision shall be provided to children ages 6 weeks to 12 years old (Infants to School age children) All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a two story home with 3 bedrooms, 2 and half bathrooms, Loft area, living area, kitchen with dining area, Family room turned into Day care room, open back yard with two side yards and an attached garage. (Laundry area is on the second level) Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. The home has a central air and heating system and the unit is installed in the side yard (Right hand side) in an off limit area with a fencing across it, making it inaccessible to children. There is a stairway leading to the second level with a child safety gate installed and there is also a fire place in the Day care room it has a metal barrier. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant states (that there are no poisons on the premises). Applicant was advised that any poisons must be locked with a key or combination lock. (1)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: AZARI, NASRIN	FACILITY NUMBER: 304313946
	VISIT DATE: 12/21/2021

NARRATIVE

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Based on the Facility Sketch submitted, areas off limits to children and parents are: Applicant has designated the second level of the home (3 bedrooms/2 bathrooms, laundry room Loft area) kitchen, and the attached garage as off-limits areas. The off- limits are made inaccessible by the applicant, by installing child safety gate at the entrance of the stairway leading to the second level of the home. There is a second metal gate installed at the entrance of the kitchen although all the kitchen cabinets have child safety latches installed on it. Door leading into the garage is in the kitchen not visible from the designated day care area, this door was locked . The Fire place is in the Day care area has a metal barrier in front, and this is bolted for safety.

During the Pre-licensing inspection, LPA observed the designated off limits areas were closed and locked.

The applicant shall use the Cell phone for Day care activities and applicant was informed if a cell phone is used for child care, it must remain on the premises at all times during hours of operation. Applicant was informed and understands the home is to be free from smoking during hours of operation.

Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Areas Designated for Day care activities: Applicant has designated the living room, family room, one half bathroom, and back yard for Day care activities.

The children shall enter through the main door of the home into the living area the designated Day Care room, adjoining to it is the family room. There is a child safety gate in-between this rooms. Applicant has designated the family room for Infant care, while living area shall be used by older children.

Upon entrance through the designated main door of the home applicant shall receive the children here, due to pandemic parents are encouraged to follow CDC guidelines, upon entrance temperatures shall be checked, hands shall be sanitized, before children are guided into the designated day care areas.

The designated Child Care room was observed to have age appropriate toys, arts and craft materials, books and educational items. Children shall nap in this area. Children shall nap on cots, linens and blankets shall be provided by the parents and applicant does have additional linens if needed.

Infant Care: Applicant has items for Infant care : Portable pac & play, changing table/ high chair, potty chair and step stool. (Page-2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: AZARI, NASRIN	FACILITY NUMBER: 304313946
	VISIT DATE: 12/21/2021

NARRATIVE

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Applicant shall provide AM/PM snacks , lunch shall be brought from home and these containers shall be labelled with their names by the parents and stored accordingly.

The bathroom is located next to the main door of the home, children will walk from the living area to access the bathroom. It was observed to be safe and free of hazardous items. There are no cabinets under the sink Applicant has a toddler potty chair / step stool, she plans to provide toilet training to the young toddlers.

OUTDOOR PLAY AREA: Applicant have designated the open back yard for outdoor activities for enrolled children. The backyard is completely fenced covered with concrete flooring. Outdoor play equipment's are arranged under the shaded area , left hand side yard is open and shall be used for tricycle rides .

The yard edges has a green mesh fencing through out in front of the plants. Right hand side yard is made inaccessible to children with a barrier gate.

Per applicant there are no firearms, weapons or bodies of water in the home.

Applicant has two pet dogs, they shall be kept in off limit areas during operating hours. Applicant has been advised to ensure the Dog food is not in the Day Care areas.

The value on the 2A10BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable. Applicant has mounted Fire extinguisher in the Day care area

Applicant have completed the required Mandated Reporter Child Abuse training, Health and Safety with Nutrition and Lead Poisoning component training and Pediatric First Aid and CPR which is valid through 2/2022 There are first aid supplies available.

The following was discussed with the applicant:·Applicant Ms. Azari, Nasin was reminded that all adults 18 and over living or working in the home, 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.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 3 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: AZARI, NASRIN	FACILITY NUMBER: 304313946
	VISIT DATE: 12/21/2021

NARRATIVE

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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 and CPR certification, TB clearance along with a valid criminal record clearance associated to the facility license.

Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
·The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

Applicant was also made aware of the Child Advocacy program so she could receive the updated Quarterly reports and other information in a timely manner. ChildCareAdvocatesProgram@dss.ca.gov

Reporting Requirements: 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.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

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

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

No smoking, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients. (Page-4)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 4 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: AZARI, NASRIN	FACILITY NUMBER: 304313946
	VISIT DATE: 12/21/2021

NARRATIVE

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Incidental Medical Services (IMS): 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: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

Infant care: Applicant shall provide Infant care, all Infant items : diapers / wipes/ lotions and milk shall be provided by the parents. Mother's milk shall be labeled and stored appropriately. There is a changing table/ sleeping cribs and play mats for the infants. Applicant shall ensure the infants are supervised at all times during her care.

Infant Care: Applicant states that she will care for infants. LPA advised the Applicant to sleep infants where they can always be directly supervised and advised against sleeping infants in a separate room. The Applicant states the following as a supervision plan for infants: The infants will sleep where she will be providing supervision and they shall not be left unattended. LPA provided a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. Online copy can be downloaded at: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with applicant the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used if they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

Hard copy and link of Child Care Providers Guide to Safe Sleep provided to licensee on this day: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf (Page-5)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 5 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: AZARI, NASRIN	FACILITY NUMBER: 304313946
	VISIT DATE: 12/21/2021

NARRATIVE

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

LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms: All the forms were provided to the Applicant during the Pre-Licensing inspection today.
Following forms were discussed and given to the applicant:

Distributed and explained the following sample forms packet:
Children Records: LIC: 700 Identification And Emergency Information, LIC 995E Caregiver Background Check Process, 995A Notification of Parent’s Rights, 627 Consent For Emergency Medical Treatment, 613A Personal Rights, LIC282 Affidavit Regarding Liability Insurance, LIC9150 Parent Notification, Additional Children in Care.
Facility Records: LIC9149 Property Owner/Landlord Consent, PUB 394 Notification of Parents Rights, LIC 9040 Facility Roster, LIC6101A Emergency Disaster Plan, LIC9148 Earthquake Preparedness Checklist, LIC 624 Unusual Incident/Injury Report.
Staff Records: LIC 508 Criminal Record Statement, LIC 501 Personnel Record, LIC 503 Health Screening/TB, LIC9052 Employee Rights, LIC9108 Statement Acknowledging Requirement to Report Child Abuse, LIC 9163 Request for LIVESCAN, LIC9188 Criminal Record Exemption Transfer Request, LIC 9182 Criminal Background Clearance Transfer Request, MMR, TDAP, FLU, Mandated Reporter Training Certificate.
OTHER INFORMATION AND FORMS PROVIDED: Capacity Handout for a Small Family Child Care Home

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 6 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: AZARI, NASRIN	FACILITY NUMBER: 304313946
	VISIT DATE: 12/21/2021

NARRATIVE

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Safe Sleep

LPA discussed the safe sleep regulations with Applicant Ms.Azari Nasrin 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 Ms. Azari Nasrin 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.

Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

The facility at the time of Pre-licensing inspection is in compliance for a (Small Family Child Care Home) with Title 22 Regulations. License shall be issued after management approval.

Appeal rights were presented and Exit interview was conducted with the Licensee Ms. Azari, Nasrin

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

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