434413536-4-29-2022-07-CC-OCAO-CDXPQD-20220429113100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413536
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:31:10 AM

Document Has Been Signed on 04/29/2022 11:31 AM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	MIRILAVASANI, HENGAMEH		FACILITY NUMBER:	434413536
ADMINISTRATOR:	HENGAMEH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 806-7181
CITY:	LOS GATOS	STATE: CA	ZIP CODE:	95032
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 12	DATE:	04/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Hengameh Mirilavasani		TIME COMPLETED:	11:35 AM

NARRATIVE

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Licensing Program Analyst (LPA) Ofelia Calivo met with Licensee Hengameh Mirilavasani for an unannounced Required - 1 Year Inspection. Also present in the home were Licensee's two helpers and 12 daycare children. LPA was granted access to the home by the Licensee and toured both indoor and outdoor areas during the inspection. LPA observed all required posted materials. Days and hours of operation for the facility are Monday through Friday from 8:00 AM to 5:00 PM. There are no active waivers or exceptions for this facility. Licensee is the only person lives in the home.

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.

LPA reviewed and obtained a copy of facility roster (LIC 9040). Fire/disaster drill was conducted on April 21, 2022. LPA observed a fully charged 3A40BC fire extinguisher and functioning smoke and carbon monoxide detectors. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. Licensee states that there are no weapons or firearms in the home.

Indoor licensed areas of the facility were inspected by LPA today and observed to be clean, orderly, and safe for the day care children. Off-limit areas in the home: office, bathroom 2, bedroom 2 and the closet. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furnitures such as tables, chairs, couches, and shelves are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via individual water bottles. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 806-7181.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Ofelia Calivo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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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Document Has Been Signed on 04/29/2022 11:31 AM - It Cannot Be Edited

Created By: Ofelia Calivo On 04/29/2022 at 10:47 AM

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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MIRILAVASANI, HENGAMEH	FACILITY NUMBER: 434413536
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Licensee and her two helpers, S2 and S3, Mandated Reporter Training certificares are expired which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2022
	Plan of Correction
1 2 3 4	LIcensee, S2 and S3 will take the online training for Mandated Reporter Training and will submit via email to LPA Calivo proof of their training certificated on or before the POD due date, May 30, 2022,

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Diana Stephenson

LICENSING EVALUATOR NAME:

Ofelia Calivo

LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MIRILAVASANI, HENGAMEH	FACILITY NUMBER: 434413536
	VISIT DATE: 04/29/2022

NARRATIVE

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The outdoor licensed areas of the home were inspected and observed to be fenced in. Off-limit areas: the garage. There are no off-limit outside the home. There were no bodies of water observed.

Twelve children’s files were reviewed during today’s inspection for the following records: Notification of Parents Rights (LIC 995A), Consent for Emergency Medical Treatment (LIC 627), Identification and Emergency Information (LIC 700), and Immunization Records. Licensee carries daycare insurance.

LPA reviewed Licensee and two helper's files for the following records: Criminal Record Statement (LIC 508), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), Employee Rights (LIC 9052), Immunization in measles, pertussis and flu, and Mandated Reporter Training. Licensee has Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and flu. The Licensee has Mandated Reporter Training that expired on 11/11/20. Licensee’s two helpers had expired Mandated Reporter Training certificates. Licensee's CPR/First-Aid certificates are current. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

LPA discussed the safe sleep regulations with the Licensee 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 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.

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

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Ofelia Calivo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MIRILAVASANI, HENGAMEH	FACILITY NUMBER: 434413536
	VISIT DATE: 04/29/2022

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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Exit interview conducted and report was reviewed with the Licensee Hengameh Mirilavasani.

As a result during today's inspection, one Type B deficiency is cited.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Ofelia Calivo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

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