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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313622440
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:02:40 PM

Document Has Been Signed on 06/02/2023 12:02 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
RIVER CITY (SACTO)CC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KHODAIE, AZITAFACILITY NUMBER:
313622440
ADMINISTRATOR:KHODAIE, AZITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 705-7275
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Azita KhodaieTIME COMPLETED:
12:05 PM
NARRATIVE
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On June 2t, 2023, Licensing Program Analyst (LPA) Jeremey McClain met with Licensee Azita Khodaie for an unannounced required annual inspection.

LPA observed a census of six children ages 2,3,3,3,3, and 3. Licensee’s mother and daughter were assisting in care today. Licensee stated there aren’t new residents in the home. All adult residents have criminal record clearances.

LPA toured areas of the home accessible to the children. The off-limit areas of the home were inaccessible.

LPA observed current CPR/First Aid certificate which expires 07/22/2023. LPA observed the following posted: a license, a Parents' Rights Poster and an Emergency Disaster Plan. LPA observed that licensee has current completion of AB1207 Mandated Reporter training which expires 07/28/2023. LPA provided Licensee with website: http://childcare.mandatedreporterca.com/ and reminded the licensee that the training must be completed once every two years.
LPA reviewed children's records for completeness, as well as the client roster. LPA observed records of immunizations for MMR, Pertussis, and influenza/ influenza declination.

LPA observed that hazardous items (detergents, cleaning compounds, medication, sharp utensils, and other items that could pose a danger to children in care) are properly stored out of children's reach. Equipment and furnishings in areas where children are active appeared to be safe and in working order. LPA observed a fireplace that was properly screened, and stairs were properly barricaded. LPA observed a working telephone in the home. Licensee stated that there are no weapons in the home. LPA observed a fire extinguisher which was last serviced on 08/21/2022. Carbon monoxide and smoke detectors were tested and observed to be functional. (1/2)
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KHODAIE, AZITA
FACILITY NUMBER: 313622440
VISIT DATE: 06/02/2023
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LPA observed fire drills documented on a calendar, indicating that the licensee is conducting disaster drills at least once every 6 months.

Equipment and furnishings in areas where children are active appeared to be safe and in working order. Appropriate nap equipment for infants was observed. Licensee has conducted and documented 15-minute sleep checks for infants.

LPA did not observe any standing bodies of water during today’s inspection.

This facility does not currently provide Incidental Medical Services- IMS. 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.

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.

No deficiencies were observed during today’s inspection.



This report was reviewed with licensee, and an exit interview was conducted.

A Notice of Site Visit was provided and should remain posted for 30 days.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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