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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313622440
Report Date: 06/12/2024
Date Signed: 06/12/2024 01:53:29 PM

Document Has Been Signed on 06/12/2024 01:53 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KHODAIE, AZITAFACILITY NUMBER:
313622440
ADMINISTRATOR/
DIRECTOR:		KHODAIE, AZITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 705-7275
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
06/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Ziba ZendehdelTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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At 12:00 pm on 06/12/2024, Licensing Program Analyst (LPA) Jeremey McClain met with facility representative Ziba Zendehdel for an unannounced annual inspection. Ziba stated that licensee Azita Khodaie was not currently present as she was attending a doctor’s appointment. Ziba stated that Azita left at approximately 11:15 am. Assistant Reyhana Abbusi was also present during the inspection.

LPA observed care and supervision of eight children (six preschool aged children and two infants). Facility representative stated there aren’t new residents in the home.

All individuals subject to criminal record review have obtained clearance.
Facility representative was reminded that all adults 18 and over living or working in the home, 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 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 04/2025. LPA observed the following posted: a license, a Parents' Rights Poster and an Emergency Disaster Plan. LPA reviewed children's records for completeness, as well as the client roster.

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. LPA observed a fireplace that was properly screened. Stairs were properly barricaded. LPA observed a working telephone in the home. Facility representative stated that there are no weapons in the home. LPA observed a fire extinguisher which licensee stated was serviced or change within the past year. Carbon monoxide and smoke detectors were tested and observed to be functional. Continued…
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KHODAIE, AZITA
FACILITY NUMBER: 313622440
VISIT DATE: 06/12/2024
NARRATIVE
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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 discussed the safe sleep regulations with licensee 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 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.
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.

During the exit interview, the licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Deficiencies were observed during today’s inspection and are cited on the following page of this report. Deficiencies pose a potential threat to the health and safety of children in care.

A notice of site visit was given and must remain posted for 30 days. Appeal Rights were provided. Exit interview conducted and report was reviewed with the facility representative Ziba Zendehdel.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2024 01:53 PM - It Cannot Be Edited


Created By: Jeremey McClain On 06/12/2024 at 01:22 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KHODAIE, AZITA
FACILITY NUMBER: 313622440

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's inspection and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. When LPA arrived at 12:00 pm, assistant Ziba Zendehdel stated that licensee Azita Khodaie had been at a doctor's appointment since 11:15 am. Licensee had not returned to the home by the end of LPA inspection, which is past 20% of licencee's operating hours (7:00am-5:30pm) which were established on 07/12/2018.
POC Due Date: 06/21/2024
Plan of Correction
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Licensee will develop a provide a written plan to LPA on how she plans to be present at the child care for 80% of operating hours by the POC due date of 06/21/2024.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 as both assistants did not have proof of immunization fro influenza, pertussis, and measles. Assistants were also missing other required from form LIC 126 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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LIC provided a copy of LIC 126 and the LIC 859 created today. Assistants will provide proof of immunizations and other missing items listed on LIC 859 by the POC due date 07/12/2024 Proof shall be provided to LPA.
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:Keven Peters
LICENSING EVALUATOR NAME:Jeremey McClain
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2024 01:53 PM - It Cannot Be Edited


Created By: Jeremey McClain On 06/12/2024 at 01:22 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KHODAIE, AZITA
FACILITY NUMBER: 313622440

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

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 as two out of eight children did not have the required forms specified above. Further more, the same children were missing required records listed on LIC 311D, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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LPA provided a copy of LIC 857, which details the forms and records that were not observed during record review on 06/12/2024. Records shall be completed and proof shall be sent to LPA by the POC due date 07/12/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Keven Peters
LICENSING EVALUATOR NAME:Jeremey McClain
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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