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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314029
Report Date: 08/09/2022
Date Signed: 08/09/2022 02:02:39 PM

Document Has Been Signed on 08/09/2022 02:02 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:GOLIPOURSAKEZABADI, ZOHREHFACILITY NUMBER:
304314029
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
08/09/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Applicant Ms. Golipoursakezabadi, Zohreh TIME COMPLETED:
02:15 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.Golipoursakezabadi, Zohreh who provided a tour of the new home.

A review of the Facility Personnel Report Summary indicates adult resident, 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 7:00 AM to 5:30 PM and care and supervision shall be provided to children ages New born to 8 years (Infants to School 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 condo family home with 2 bedrooms, 1 and a half bathroom, laundry room, Kitchen with dining area and the back patio with storage closet and an additional wooden shed. There is a stairway in the home leading to the second level of the home.

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 back patio area it has a safe cover making it safe and 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 lock. (1)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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: GOLIPOURSAKEZABADI, ZOHREH
FACILITY NUMBER: 304314029
VISIT DATE: 08/09/2022
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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 which has two bedrooms, one full bathroom and the laundry room and applicant has installed a child safety gate at the entrance of the stairway making the second level inaccessible to children. Kitchen is open and the cabinet under the sink has a child safety lock installed making the kitchen and dining area safe. There is a closet under the stairway in the living area and Applicant has installed a child safety latch on the door making it inaccessible to children.

There is no fire place in the family child care home.

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 living area, one half bathroom, kitchen with dining area and the back patio area for Day care activities.

Children shall enter the home through the main door on the first level, leading directly into the living area the designated Day care room. The living area is the designated activity room for all the children to be served and Infant care shall be provided here. The day care room was observed to be well lighted and ventilated with vinyl flooring. Age appropriate activities are arranged. There is sufficient storage space for children. Older Infants & children shall nap on mats and younger infants in the portable pac/play pens. . Dining activity shall be held in the kitchen/ dining area. Applicant has age appropriate Infant furniture including small dining table with chairs and portable chairs with trays for infants to be served. Changing table has been placed outside the bathroom in the hallway. Infant toys and activities are present in the home. There are activities for older children also in the home.

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

All the items needed for younger infants shall be provided by the parents, including Diapers/ lotions and wipes. Mother's milk shall be labelled and stored separately. (2)

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

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
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: GOLIPOURSAKEZABADI, ZOHREH
FACILITY NUMBER: 304314029
VISIT DATE: 08/09/2022
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Children's bathroom is located in the passage area, It is a half bathroom, children shall walk through the living area to access the designated bathroom. Applicant has small step stool and toddler toilet seat for the older infants. Cabinets under the sinks has child safety locks installed. The children's bathroom was observed to be safe and free of hazardous items.

LPA's discussed the Safe Sleep practice with the Applicant Ms. Golipoursakezabadi, Zohreh



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.
Licensee shall maintain LIC 9227 form in the infant file. ( Printed and given to the applicant)

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

Upon entrance through the designated main door of the home on the first level, 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.

OUTDOOR PLAY AREA: Applicant has designated the back patio area for outdoor activities, it completed fenced with concrete flooring, there is an additional exit door with a bolt lock. Wooden shed and A/C unit are are made inaccessible. Shade is provided through the structure roof line shade. There are age appropriate activity items for children to be served. (3)

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

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
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: GOLIPOURSAKEZABADI, ZOHREH
FACILITY NUMBER: 304314029
VISIT DATE: 08/09/2022
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There are no pets, Bodies of Water or firearms or weapons, 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 placed the Fire extinguisher on the side wall of the kitchen. Smoke &Carbon Monoxide detectors are mounted on the ceiling of the living area, kitchen & in each of the two bedrooms on the second level



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 04/13/2024. 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.

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. (4)

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

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: GOLIPOURSAKEZABADI, ZOHREH
FACILITY NUMBER: 304314029
VISIT DATE: 08/09/2022
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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 discussed the following items with the applicant Ms. Golipoursakezabadi, Zohreh during the Exit interview:

Criminal Record statement: Applicant Ms. Golipoursakezabadi, Zohreh 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. Golipoursakezabadi, Zohreh & discussed the Child Care Licensing Safe Sleep web page 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.Golipoursakezabadi, Zohreh 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 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. Golipoursakezabadi, Zohreh 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. (LPA provided all the LIC forms listed on LIC 311D, including additional information packet to the Applicant) (5)

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

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
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: GOLIPOURSAKEZABADI, ZOHREH
FACILITY NUMBER: 304314029
VISIT DATE: 08/09/2022
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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 license- 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.


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 .

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.

This report was read and Appeal rights were presented to the Applicant Ms. Golipoursakezabadi, Zohreh. .

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

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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