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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313946
Report Date: 01/03/2024
Date Signed: 01/03/2024 02:44:13 PM

Document Has Been Signed on 01/03/2024 02:44 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:AZARI, NASRINFACILITY NUMBER:
304313946
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
01/03/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:LicenseeTIME COMPLETED:
03:15 PM
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A Required -3 Year inspection was conducted at the facility by Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek. LPA met with licensee, Nasrin Azari who was taking care of 3 children of whom all were under 24 months old. Licensee was operating within the licensed capacity as specified on license.
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.
Currently there are two adults including the licensee and no minor children living in the facility. Facility Day care hours of operation is Monday through Friday from 6:30 am-6:30 pm.
During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of baby gates and locks. The childcare area consists of living room, and family room, and children's bathroom and outdoor patio with backyard. Kitchen is separated by a baby gate from family room. Door leading to garage was located in the kitchen area on the other side of the baby gate which was locked and inaccessible. Main childcare room is accessed upon entering the home. There is a baby gate installed between the family room and living room which are used for children's area. Fire place is barricaded. Upstairs area is off limit and a baby gate was installed on the bottom of the stairs. There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger to children were not readily available to children they were stored inaccessible to children, none were observed during inspection. Licensee stated there is no firearm in the facility. There are two dogs kept in garage ( Chihuahua Breed). LPA observed 3 playpen in the children's area. There is a diaper changing table against the wall in the children's area in the family room that has a high raise bar on the sides. LPA reminded the licensee that children shall not be left unattended on the changing table during diaper changing.
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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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: AZARI, NASRIN
FACILITY NUMBER: 304313946
VISIT DATE: 01/03/2024
NARRATIVE
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LPA verified there is a working telephone service (cellular service). Licensee stated, they use back patio and backyard for outdoor play. The outdoor area was fenced. The front yard is barricaded with plastic gate. There is a two tier water fountain located on the high slope four feet above the ground with no water in it. The licensee stated the fountain is not operable.
The licensee does not have a current roster of children in care. Fire Drill log was reviewed with the licensee. A log was given to her to log the fire drill every 6 months. The licensee started working two months ago. 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) and found to be in compliance. The log for very 15 minutes check on napping children under 24 months old was available. (Total of 3 files were reviewed. LIC 9227 form for infants under 2 months were missing for two children.
The licensee's Pediatric CPR/First Aid certification expires 7/31/2024. However the certificate is not EMSA approved. 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 was reviewed and within compliance. 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 is exempt since the training is not offered in her native language.
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/.
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. LPA provided Guardian Information and website info:
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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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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: AZARI, NASRIN
FACILITY NUMBER: 304313946
VISIT DATE: 01/03/2024
NARRATIVE
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https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian
Licensee, Nasrin Azari 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, 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 licensed Family Child Care Home. 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.

LPA discussed the safe sleep regulations with Licensee, Nasrin Azari 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, Nasrin Azari 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.

Licensee, Nasrin Azari was informed of the MyChildCarePlan.org site, 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. 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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-care- licensing/subscribe and select the Child Care option to receive email communication. (The licensee is already signed up for this purpose).

In the areas that were evaluated, The following deficiencies were observed of the California Code of Regulations, Title 22, Division 12 on this inspection date. Please refer to LIC 809Ds. A notice of site visit was given to licensee, Nasrin Azari and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with the licensee, Nasrin Azari

End of report

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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Document Has Been Signed on 01/03/2024 02:44 PM - It Cannot Be Edited


Created By: Mahnaz Malek On 01/03/2024 at 01:49 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: AZARI, NASRIN
FACILITY NUMBER: 304313946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which posed a potential health, safety risk to persons in care. The licensee's CPR and 1st aid certificate expires 7/2024. However the certificate is not EMSA approved.
POC Due Date: 01/17/2024
Plan of Correction
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The licensee agreed to take the training again with an EMSA approved agency. Licensee will send the proof to LPA by the due date of 1/17/2024
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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Based on record review, the licensee did not comply with the section cited above in count of one out of 3 files which poses potential health, safety risk to persons in care. Child # 3 did not have any immunization on file.
POC Due Date: 01/17/2024
Plan of Correction
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Licensee agreed to obtain the immunization for child # 3 and send the proof to LPA by due date of 1/17/2024
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:Thuy Ho
LICENSING EVALUATOR NAME:Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


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Document Has Been Signed on 01/03/2024 02:44 PM - It Cannot Be Edited


Created By: Mahnaz Malek On 01/03/2024 at 01:49 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: AZARI, NASRIN
FACILITY NUMBER: 304313946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 counts out of 3 files which posed a potential health, safety risk to persons in care. Child # 1 and child # 2 were missing these forms on their files.
POC Due Date: 01/17/2024
Plan of Correction
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Licensee agreed to submit these signed forms for child # 1 and 2 and send it to LPA's email by the due date of 1/17/24.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which posed a potential health, safety risk to persons in care. The facility did not have a roster.
POC Due Date: 01/17/2024
Plan of Correction
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Licensee agreed to submit a completed roster of children to LPA by the due date of 1/17/2024.
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:Thuy Ho
LICENSING EVALUATOR NAME:Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/03/2024 02:44 PM - It Cannot Be Edited


Created By: Mahnaz Malek On 01/03/2024 at 01:49 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: AZARI, NASRIN
FACILITY NUMBER: 304313946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

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
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3
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Based on record review, the licensee did not comply with the section cited above in 2 counts of 3 files which posed a potential health, safety risk to persons in care. Child # 1 and 3 were missing LIC 9227 on their files.
POC Due Date: 01/17/2024
Plan of Correction
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Licensee agreed to submit the completed forms for child # 1 and 3 to LPA by the due date of 1/17/2024
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Thuy Ho
LICENSING EVALUATOR NAME:Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


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