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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376102009
Report Date: 08/23/2024
Date Signed: 08/23/2024 04:03:25 PM

Document Has Been Signed on 08/23/2024 04:03 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:HEIDARI, MASOUMA FAMILY CHILD CAREFACILITY NUMBER:
376102009
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
08/23/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Heidari MasoumaTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 8/23/24 at 1:30PM Licensing Program Analyst (LPA) Patrick Ma conducted an unannounced inspection for an increase in capacity application with the applicant Masouma Heidari. Fire clearance was completed on 7/1/24. The 2-story home was toured and inspected to ensure an environment safe for the care and supervision of children. Present in the home was one day care child who is under 24 months and 1 of licensee’s own child under the age of 10. Licensee stated she has 8 children enrolled and the other children would be dropped off by their parents in the afternoon. No other children arrived during inspection.
Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include living room, kitchen, classroom, room 1, bathroom, and backyard. Off limits areas are garage and entire 2nd floor and are inaccessible through use of gate at the bottom of the stairs, but garage needs to be made inaccessible to children. The home has a fully fenced backyard available for outdoor activities. Unevenly piled bricks, construction debris and equipment were observed on both the left and right portion of the backyard.

The fire extinguisher, smoke detector, and carbon monoxide detector meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. There is no body of water on the property. Licensee states that there are no weapons in the home. First Aid and CPR certifications expire on 12/13/24. Licensee has required immunizations. Licensee completed Mandated Reporter Training on 1/27/23 and is reminded it must be completed every 2 years. Children’s records were reviewed and found missing required documents.

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.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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 5
Document Has Been Signed on 08/23/2024 04:03 PM - It Cannot Be Edited


Created By: Patrick Ma On 08/23/2024 at 02:05 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: HEIDARI, MASOUMA FAMILY CHILD CARE
FACILITY NUMBER: 376102009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
HSC
1596.8555

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1596.8555 A licensed child day care facility shall post its license in a prominent, publicly accessible location in the facility. A family day care home shall comply with this posting requirement during the hours when clients are present.
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Licensee posted license during inspection. Deficiency cleared.
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Based on observation and interview, daycare license (LIC203) was not posted and licensee stated that nobody told her it needed to be posted which poses/posed a potential health, safety or personal rights risk to children in care.
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Type B
08/23/2024
Section Cited
CCR102417(g)(10)(b-c)

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102417(g)(10)(b-c) A baby walker shall not be kept or used on the premises of a child day care facility…A "baby walker" means any article described in paragraph (4) of subdivision (a) of Section 1500.86 of Part 1500 of Title 16 of the Code of Federal Regulations.
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Licensee removed baby bouncer from licensed daycare area and placed in garage during inspection. Deficiency cleared.
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Based on observation, baby bouncer was observed in room 1 during facility tour which poses/posed a potential health, safety or personal rights risk to children in care.
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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:Renesha Askew
LICENSING EVALUATOR NAME:Patrick Ma
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/23/2024 04:03 PM - It Cannot Be Edited


Created By: Patrick Ma On 08/23/2024 at 02:18 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: HEIDARI, MASOUMA FAMILY CHILD CARE
FACILITY NUMBER: 376102009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
CCR
102417(g)

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102417(g) The home shall be free from defects or conditions which might endanger a child...
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Licensee stated she will remove the outdoor debris or fence them off and provide proof to the Department by 9/20/24.
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Based on observations, unevenly piled bricks, construction debris and equipment was observed on both the left and right portion of the backyard which poses/posed a potential health, safety or personal rights risk to children in care.
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Type B
09/20/2024
Section Cited
CCR102417(g)(8)

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102417(g)(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidenced by:
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LPA provided licensee a blank Children's roster (LIC 9040). Licensee stated she will submit proof of a completed children's roster of the 8 children currently enrolled to the Department by 9/20/24.
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Based on records review, Licensee did not have a children's roster and stated she did not know what it was which poses/posed a potential health, safety or personal rights risk to children in care.
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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:Renesha Askew
LICENSING EVALUATOR NAME:Patrick Ma
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/23/2024 04:03 PM - It Cannot Be Edited


Created By: Patrick Ma On 08/23/2024 at 03:06 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: HEIDARI, MASOUMA FAMILY CHILD CARE
FACILITY NUMBER: 376102009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
CCR
102421(a)

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102421(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
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Licensee stated she will submit proof of all missing children's documents to the Department by 9/20/24.
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Based on records review, C1 was missing LIC 282 and LIC 995A, C4 and C5 were missing all required documents which poses/posed a potential health, safety or personal rights risk to children in care.
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Type B
09/20/2024
Section Cited
CCR102425(j)(1-2)

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102425(j)(1-2) INFANT SAFE SLEEP: The provider shall supervise infants while they are sleeping and…check on the infant every 15 minutes…provider shall check and document.
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Licensee stated she will begin to record sleep logs for all children under 24 months and provide a documented sample of C1's sleep log to the Department by 9/20/24.
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Based on records review and interview, licensee had a blank example of a sleep log posted but had no sleep log records for child C1, in licensee's care for over 7 months which poses/posed a potential health, safety or personal rights risk to children in care.
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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:Renesha Askew
LICENSING EVALUATOR NAME:Patrick Ma
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: HEIDARI, MASOUMA FAMILY CHILD CARE
FACILITY NUMBER: 376102009
VISIT DATE: 08/23/2024
NARRATIVE
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LPA discussed the safe sleep regulations with applicant 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 applicant 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 owns the home and can operate with a maximum capacity of 14 children if large license is approved. Capacity limitations were reviewed. Licensee is to be present in the home to ensure children are supervised and is reminded that the license is NOT transferable, and should she relocate, this license will be null and void.

See LIC809D for deficiencies cited.

The following corrections are needed:
• Deficiency corrections
• Garage door from dining room needs to be made inaccessible

Applicant understands that corrections must be submitted to the Department within 30 days or the application may be denied. After all corrections are submitted and reviewed, a large Family Child Care Home license may be issued upon final file review. Licensee was reminded that annual fees are due on the date they were licensee every year.

Exit interview conducted and report was reviewed with the applicant Masouma Heidari. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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