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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415136
Report Date: 11/08/2021
Date Signed: 11/08/2021 08:24:21 PM

Document Has Been Signed on 11/08/2021 08:24 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:JALILVAND, FARNOUSHFACILITY NUMBER:
434415136
ADMINISTRATOR:JALILVAND, FARNOUSHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 616-0022
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Farnoush JalilvandTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA), Marilou Monico, met with Licensee, Farnoush Jalilvand, for an unannounced Required - 1 Year Inspection. LPA was granted access to the home by the Licensee and toured both indoor and outdoor areas during the inspection. Also present in the home were licensee's adult employee and four children including three (3) preschool age and one (1) infant. LPA observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday, 7:30 AM- 6:00 PM. There are no active waivers or exceptions for this facility. Licensee states that she is the only adult residing in the home together with her two minor children ages: 15 and 9 years old.

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 facility roster (LIC9040). Fire/disaster drill was conducted on July 2, 2021 and documented. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke detectors 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.

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 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: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: JALILVAND, FARNOUSH
FACILITY NUMBER: 434415136
VISIT DATE: 11/08/2021
NARRATIVE
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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-limits areas of the indoor facility include: bedrooms 1 and 2, patio/atrium area, master bathroom, and garage. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, 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 filtered water and sippy cups. The bathroom in the home is clean, sanitary, and operable. The Licensee has a working telephone which is (408) 616-0022 in the facility.

The outdoor licensed area of the home was inspected and observed to be fenced in. There are no off limit areas outside the home. LPA observed play equipment was in good condition and age-appropriate. There were no bodies of water observed.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page 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.

Five (5) children’s files (2 infants and 3 preschool-age) were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC282), and Immunization Records (PM286).

Licensee file and helper's file were reviewed for the following records: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Employee #1 is missing immunization in measles and pertussis. The Licensee has expired Mandated Reporter Training. Licensee's CPR/First-Aid expires April 5, 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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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: JALILVAND, FARNOUSH
FACILITY NUMBER: 434415136
VISIT DATE: 11/08/2021
NARRATIVE
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Supervision of children was discussed with the Licensee and she understands that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Farnoush Jalilvand.

As a result of todays inspection, deficiencies were cited on the following page.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2021 08:24 PM - It Cannot Be Edited


Created By: Marilou Monico On 11/08/2021 at 11:23 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: JALILVAND, FARNOUSH
FACILITY NUMBER: 434415136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021

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
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Based on record review, the licensee has expired Mandated Reporter Training. This poses a potential risk to the health, safety or personal rights to children in care.
POC Due Date: 12/08/2021
Plan of Correction
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Licensee states she will submit her current Mandated Reporter Training certificate by December 8, 2021.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Employee #1 is missing immunization in measles and pertussis. This poses a potential risk to the health, safety or personal rights to children in care.
POC Due Date: 12/08/2021
Plan of Correction
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Licensee states that she will submit proof if immunization in measles and pertussis for her employee by December 8, 2021.
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:Anthony Studebaker
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021


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