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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100829
Report Date: 08/26/2021
Date Signed: 08/26/2021 01:25:39 PM

Document Has Been Signed on 08/26/2021 01:25 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:AGHA MOHAMMADI, MAHDIE FAMILY CHILD CAREFACILITY NUMBER:
376100829
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/26/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mahdie Agha MohammadiTIME COMPLETED:
01:40 PM
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On 8/26/21 Licensing Program Analyst Michael Morales-DeSilvestore conducted an announced Pre-Licensing inspection for relocation with the applicant. The Applicants adult son Parvis Tavasolli was present to translate to Farsi. The 1 story home was toured and inspected to ensure an environment safe for the care and supervision of children. The fire extinguisher and carbon monoxide detector meet requirements and are operational. The facility did not have a working smoke detector. All hazardous items were latched/locked and secured out of reach of children. There are no bodies of water in the home. Applicant states that there are no weapons in the home. CPR and First Aid expire on February 2022. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Staff immunization requirements were met. Applicant owns the home.

Applicant will be using the following rooms for childcare: Living Room 2, bedroom 2, bathroom 1, kitchen and living room 1. Off limits areas include: bedroom 1, bedroom 3 and bathroom 2 and are inaccessible through the use of door knob covers. The garage will also be off limits and is kept inaccessible through the use of the garage door. There is no direct access to the garage through the house. The applicant has sufficient toys and equipment available. The home has a fenced backyard available for outdoor activities.

Applicant was reminded of requirements for children’s records, child abuse, and unusual incident reporting, immunizations, adults living or working in the home and associated civil penalties, applicant was also reminded that corporal punishment, smoking, walkers, exersaucers, bouncy seats and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA provided information regarding Safe Sleep Regulations/SIDS and Shaken Baby Syndrome. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Michael Morales-DeSilvestore
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: AGHA MOHAMMADI, MAHDIE FAMILY CHILD CARE
FACILITY NUMBER: 376100829
VISIT DATE: 08/26/2021
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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.

The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. LPA provided notice of site visit and observed it being posted at the facility.

The following corrections are needed prior to issuing the license: Fireplace screen, smoke detector and wall postings. Applicant will submit corrections by 9/3/21.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Michael Morales-DeSilvestore
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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