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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313991
Report Date: 04/05/2022
Date Signed: 04/05/2022 03:36:59 PM

Document Has Been Signed on 04/05/2022 03:36 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:ARJOMAND, MARYAMFACILITY NUMBER:
304313991
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
04/05/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Applicant Ms. Arjomand, Maryam TIME COMPLETED:
03:50 PM
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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. Arjomand, Maryam who provided a tour of the new Small Family Child care 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 7:30 AM to 6:00 PM and care and supervision shall be provided to children ages 4 months to 5 years only ( Infants to Preschool age children only)

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a two story Single family home with 3 bedrooms, 2 and a half bathrooms, laundry room, living area, dining area, kitchen, Side yard, backyard with an attached garage.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone is the primary contact phone. Ventilation and heating. There is central air and heat in the home. Home has ceiling vents for air flow. The A/C unit is in the side yard with a metal mesh covering making it inaccessible to children.

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. (1)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ARJOMAND, MARYAM
FACILITY NUMBER: 304313991
VISIT DATE: 04/05/2022
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Based on the Facility Sketch submitted, areas off limits to children and parents are: Applicant has designated the entire second level of the home: three bedrooms, two full bathrooms & laundry room as off limit areas, on the first level of the home, applicant has designated the attached garage/kitchen with dining area and the back yard as off limit areas. Garage door opens in the walkway in front of the bathroom it has a bolted lock installed on it. Applicant has installed a child safety gate at the end of the living room, making the kitchen / dining area and back yard completely inaccessible to children. The second level of the home is made inaccessible by a child safety gate on the bottom of the stairway. There is no Fire place or open heaters in the home. Back yard also has two child safety gates adjoining the Barbecue area, making the back yard completely inaccessible to children.

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 area with one bathroom for Indoor day care activities portion of the room will be used for Infant care. Children shall enter through the main door of the home leading to the living room the designated for Day care activities. This room has age appropriate furniture along with educational and play activities for children.

Toddlers and Preschool age children shall nap in the living area using soft sleeping mats with blankets provided by the applicants. Dining activities shall be held on the small table. Infants shall use high chairs which are arranged in the corner. Applicant shall provides home cooked food to the enrolled children.

Living room was also observed to have napping items for infants, portable cribs, high chairs and cubbies for storage , all additional Infant items: diapers / wipes/ lotions and milk shall be provided by the parents. Mother's milk shall be labeled and stored appropriately.

LPA discussed the LIC 9227 ( Individual Sleeping plan) with the applicant.

(2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
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: ARJOMAND, MARYAM
FACILITY NUMBER: 304313991
VISIT DATE: 04/05/2022
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LPA discussed the Safe Sleep practice with the applicant Ms. Arjomand, Maryam

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.
Applicant shall maintain LIC 9227 form in the infant file.

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

The bathroom is located on the left side of the small hallway leading to the living area from the main door. Children shall walk through the living area to access the designated bathroom. Applicant has small step stool and toddler toilet seat for the younger toddlers. There is no cabinet under the sink. The children's bathroom was observed to be safe and free of hazardous items.

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

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.

Applicant has set up a sanitizing station at the entrance door of the house, on a side table. (3)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
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: ARJOMAND, MARYAM
FACILITY NUMBER: 304313991
VISIT DATE: 04/05/2022
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OUTDOOR PLAY AREA: Applicant has designated the side yard for outdoor activities. It shall be accessed from the side door outside the home, It is completely fenced and the latch on the door is at on the top of the wooden door . It has grass and concrete flooring. Shade is provided by structural roof line. Applicant has age appropriate toys for outdoor activities. Other side of the side yard - the Back yard is inaccessible and applicant has installed child safety gates making the other side completely inaccessible to children.

Home also has additional security Alarm system in the home, which shall be triggered if any doors are opened accidentally including the wooden side door in the side yard. Applicant has also installed a safety latch on this door. There is decorative water fountain in the in the backyard wall. There is no water in it only small pebbles.

There are no pets, firearms, weapons, bodies of water in the home.

The value on the 2A10 BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable. Applicant has mounted the Fire extinguisher in the garage wall , Smoke detector is mounted on the ceiling of the hallway area and Carbon Monoxide is plugged in.



Applicant have completed the required Mandated Reporter Child Abuse training, Health and Safety training with Nutrition and Lead Poisoning component and Pediatric First Aid and CPR which is valid through 1/17/2024. There are first aid supplies available.

The following was discussed with the applicant: 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-10 BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
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. . (4)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
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: ARJOMAND, MARYAM
FACILITY NUMBER: 304313991
VISIT DATE: 04/05/2022
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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 Baby walkers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility

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



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

LPA discussed the following items with the applicant Ms. Arjomand, Maryam during the Exit interview:
Criminal Record statement: Applicant Ms. Arjomand, Maryam 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.

Safe Sleep : LPA discussed the safe sleep regulations with applicant Ms. Arjomand, Maryam & 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 of the applicant Ms. Arjomand, Maryam 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.

(5)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
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: ARJOMAND, MARYAM
FACILITY NUMBER: 304313991
VISIT DATE: 04/05/2022
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APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: 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: http://www.ada.gov/childqanda.htm.

Review of records to be maintained : LPA reviewed with applicant Ms. Arjomand, Maryam the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Subscribe to CCLD important information


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 platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email 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/process.


Exit interview conducted with the Applicant Ms. Arjomand, Maryam this report was read to the applicant.

OTHER INFORMATION AND FORMS PROVIDED: Capacity Handout for a Small Family Child Care Home. LPA explained the age requirements for the enrolled children ensuring that when there are 8 children, at least one child is enrolled in Kindergarten or 6 years old, to be in compliance with Title 22 requirements.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
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: ARJOMAND, MARYAM
FACILITY NUMBER: 304313991
VISIT DATE: 04/05/2022
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LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

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 upon Management approval.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC809 (FAS) - (06/04)
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