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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623144
Report Date: 06/13/2023
Date Signed: 06/13/2023 02:35:09 PM

Document Has Been Signed on 06/13/2023 02:35 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:KOHZAD, MAHNAZFACILITY NUMBER:
343623144
ADMINISTRATOR:KOHZAD, MAHNAZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 990-1052
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
06/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Mahnaz KohzadTIME COMPLETED:
03:00 PM
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On June 13, 2023 at approximately 01:25 PM, Licensing Program Analyst (LPA) Michelle Pascual met with Licensee, Mahnaz Kohzad, for an unannounced annual / one year inspection. During the inspection there was a census of 09 CHILDREN being supervised by the licensee and assistant. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are 7AM to 5PM.

A health and safety inspection was conducted in the areas accessible to children. The off-limit areas are include: Front two rooms, Master bed/bath and garage. Licensee understands that children may never enter these off-limits areas. The house has a working telephone, fully charged fire extinguisher 2A-10BC, smoke detector and carbon monoxide detector that meet regulations. LPA observed all required postings. LPA observed home was safe, orderly, and free of hazards. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. LPA observed a fireplace that is barricaded. The licensee stated that there are no firearms or bodies of water on the premises.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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
RIVER CITY (SACTO)CC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KOHZAD, MAHNAZ
FACILITY NUMBER: 343623144
VISIT DATE: 06/13/2023
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LPA observed a children's roster and fire drill log, the last fire drill was conducted April 2023. Licensee's has current CPR/First aid, which expires March 2025. Licensee’s Mandated Reporter Training expires December 2024. Licensee understands both training’s must be completed every two years. LPAs reviewed records of children’s files, all which contained the required documentation.

Incidental Medical Services (IMS) policy was discussed. 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

Licensee 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.

Licensee is aware of safe sleep regulations but does not have infants in care.

No deficiencies were cited during today’s inspection.

Exit interview conducted and report was reviewed with the Licensee. A notice of site visit was provided and must remain posted for 30 days

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
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