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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624523
Report Date: 11/08/2023
Date Signed: 11/08/2023 12:11:11 PM

Document Has Been Signed on 11/08/2023 12:11 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:MEHDIZADE, KHADIJA & REZAI, ALIFACILITY NUMBER:
343624523
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
11/08/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Khadija MehdizadeTIME COMPLETED:
12:30 PM
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On November 8th, 2023 Licensing Program Analyst (LPA) Mandie Goodwin met with Licensee Khadija Mehdizade for the purpose of an unannounced case management inspection. Licensee has requested to increase from a small family childcare to a large family childcare. LPA observed one child during visit. All individuals subject to criminal background review have obtained a criminal record clearance. LPA verified with Licensee that her current associations are accurate.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas will include the master bedroom and garage. Licensee acknowledges that she must contact Community Care Licensing prior to making an off-limit area on-limits and vice versa. A fire clearance was granted on November 1st, 2023 for these areas.

LPA discussed CCR 102416.5 (d) which discusses the required ratios and capacity for a Large Family Child Care. Licensee understands that children under 10 years old that live in the home count towards total capacity. LPA discussed personnel records needed for adult and minor assistants.

Licensee 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.

Continued on 809-C
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEHDIZADE, KHADIJA & REZAI, ALI
FACILITY NUMBER: 343624523
VISIT DATE: 11/08/2023
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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-andresources/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.

Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for childcare updates, current forms, legislation and regulation information. This facility evaluation report was reviewed and discussed with the licensee.

In the areas that were evaluated, no deficiencies were observed.

Effective today, November 8th 2023, Licensee’s request for a Large Family Child Care License is approved. Licensee can now provide care for 12 children (when there is an assistant present) with no more than 4 infants or capacity of 14 children when 1 child in T-K or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of two years. Licensee understands that when there is no assistant present, ratios of a small capacity must be adhered to.

An exit Interview was conducted with Licensee Khadija Mehdizade & Ali Rezai and a Notice of Site Visit was provided, which should remain posted for 30 days for parental review.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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