<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500980
Report Date: 02/01/2024
Date Signed: 02/01/2024 12:33:30 PM

Document Has Been Signed on 02/01/2024 12:33 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MAHTAB, ALIFACILITY NUMBER:
394500980
ADMINISTRATOR:MAHTAB, ALIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 676-7333
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
02/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Ali MahtabTIME COMPLETED:
12:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Erwin Tjhia met with Applicant, Ali Mahtab for the purpose of a prelicensing evaluation for large family child care home. Fire clearance was granted by Lathrop-Menteca Fire Department on 01/05/2024. Applicant's husband was also present during the inspection. Applicant's tentative hours are Monday - Friday from 8:00 AM to 3:30 PM.

All individuals subject to criminal background review have obtained a criminal record clearance. Applicant 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.

A health and safety inspection was conducted inside and out. The one story home has 5 bedrooms and 5 bathrooms. The off-limits areas are entire upstairs, living room, kitchen, all bedrooms, play room on the back, garages, and swimming pool area. LPA toured the facility and verified toxic and hazardous items were inaccessible to children in care. Off-limits areas will remain inaccessible to children by doorknob covers, baby latches, gate/fence, and supervision. Outdoor play area was toured. Functioning smoke and carbon monoxide detectors were observed at the facility. 2A10BC fire extinguisher was verified and first aid kit was observed in the classroom. Home has an in ground pool located in the backyard. LPA inspected the pool fencing and observed a mesh pool fence. The mesh fencing is attached to the backyard's existing wood fencing. LPA did measurements around the fencing. The base of the fence to the top of the fence measured 5 feet 1 inch. The fencing does not obstruct the view of the pool. The gate does swings away from the pool, self closing with self latching mechanism. The self latching mechanism is located no more than six inches from the top of the gate. LPA did not observe any objects located near the pool. The fence completely surround the pool and no windows or doors provide direct access to the pool. Report Continue on 809-C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MAHTAB, ALI
FACILITY NUMBER: 394500980
VISIT DATE: 02/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA discussed the new Mandated Reporter Training with applicant. Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/. The training is currently provided in English. Applicant has a current Mandated Reporter Training Certificate and Current pediatric CPR and first aid training.

On 10/12/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders (RSOs) were found at the facility addresses. Under state law, some RSOs are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all RSOs against all Community Care Licensing Division (CCLD) facility addresses pursuant to information shared by California DOJ.



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

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-and-resources/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.

Report Continue on 809-C
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MAHTAB, ALI
FACILITY NUMBER: 394500980
VISIT DATE: 02/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction.

Applicant understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area. Applicant understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to three years.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at
https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the Applicant. Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes. As of today, Licensee will be approved for a Large Family Child Care Home to serve 12 children (when there is an assistant present) with no more than 4 infants or capacity of 14 children when 1 child in kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of 2 years old.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3