<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314029
Report Date: 05/03/2024
Date Signed: 05/03/2024 02:31:36 PM

Document Has Been Signed on 05/03/2024 02:31 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GOLIPOURSAKEZABADI, ZOHREHFACILITY NUMBER:
304314029
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
05/03/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Licensee Zohreh GolioursakezabdiTIME VISIT/
INSPECTION COMPLETED:
03:00 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) Romy Castanon and Christine Jung conducted a case management inspection, in response to licensee’s request for a capacity increase. LPA met with licensee, Zohreh Golipoursakezabadi who guided analyst on a tour of the facility. Census was taken and there were 5 preschool age children in day care area. Licensee was operating within the licensed capacity as specified on license.

Licensee stated there are currently two adults living in the home. Licensee stated she is not currently registered with any Foster Care agency or holds a foster parent license. Licensee was reminded if changes are made to notify the licensing office.

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.

This is a two-story home with 2 bedrooms, 1.5 bathrooms, living room, dining room, kitchen, front porch (not fenced), back yard (fenced). The licensee acknowledged the children may never enter the off-limit areas (second floor) during operation hours. The stairs to the second floor are secured with a baby gate. The crawl space under the stairs is used for storage and has a baby proof lock. The licensee has a cell phone that is used for childcare. The licensee was informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation. The licensee was informed and understands the home is to be free from smoking during hours of operation.

The licensee has designated the living room, dining room, kitchen and one bathroom (located between the living room and kitchen), and backyard as the day care areas. Outdoor play activities will be conducted in the backyard, which is appropriately fenced. LPA observed play equipment to be safe and free of hazards.

(Continue to page 2)

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOLIPOURSAKEZABADI, ZOHREH
FACILITY NUMBER: 304314029
VISIT DATE: 05/03/2024
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
26
27
28
29
30
31
32
Page 2

Children nap on cots in the designated living room area. Licensee stated family provides blankets for the children and licensee washes them at the end of every week or as needed. Licensee uses a changing table to change the infants or non-potty-trained children. The changing table is located outside of the downstairs restroom. LPA reminded licensee, that while changing an infant’s diaper to visually observe the infant, to ensure the infant is safe. Licensee provides breakfast, lunch, and snacks for the children.

During today’s inspection, LPA did not observe detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children and were stored inaccessible to children. Poisons and hazardous items were not observed. There are no bodies of water at the home. The smoke detector and carbon monoxide were operable, and the fire extinguisher was charged and met Fire Marshall standards. Licensee did not have a completed fire/disaster drill log. Licensee’s fire clearance was granted on 03/27/2024.

The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. Licensee stated there are no weapons or firearms on the premises. When firearms are present, they must be locked and stored separately from the ammunition.

Licensee’s Mandated Reporter certification expires on 02/26/2026. EMSA approved Pediatric CPR and Pediatric First Aid were current for licensee, which expires on 04/01/2026. The licensee has a current roster of children in care. During this inspection, LPA reviewed five children’s records, and they were in compliance.

LPA advised the licensee how to access forms, regulations and quarterly updates online at: www.ccld.ca.gov

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep


as an additional resource. LPA also informed facility representative 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. (Continue to page 3)
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOLIPOURSAKEZABADI, ZOHREH
FACILITY NUMBER: 304314029
VISIT DATE: 05/03/2024
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
26
27
28
29
30
31
32
Page 3

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.



Licensee was reminded that all adults 18 and over, 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 Child Care Family 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.

A new license for operating a Large Family Child Care Home shall be issued upon final review and if additional information is needed, licensee shall be contacted.



During todays’ inspection, there were no deficiencies cited and licensee was in compliance with California Code of Regulations Title 22 for operating a Family Child Care home.

Exit interview conducted and report was reviewed with the licensee, Zohreh Golipoursakezabadi. 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 Zohreh Golipoursakezabadi 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. (End of Report)
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3