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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415614
Report Date: 11/12/2021
Date Signed: 11/12/2021 12:01:31 PM

Document Has Been Signed on 11/12/2021 12:01 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:SHAHBAZI, SHADIEHFACILITY NUMBER:
434415614
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Shadieh ShahbaziTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ofelia Calivo met with Licensee Shadieh Shahbazi 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 mother, Lili Akhavan, and Licensee’s two minor children ages 13 and 6 years old. LPA observed no day care children and Licensee stated she did not have day care children since she was licensed in September 17, 2020. LPA observed all required postings near the entrance of the home. Hours of operation for the facility are Monday through Friday, 7:00 am to 6:00 pm.

The off-limit areas inside the home include all bedrooms, living room and the garage. The off-limit areas outside the home include portion of the yard separated by a divider. Prior to utilizing any off-limit areas inside and outside of the home, Licensee shall inform Licensing office. LPA observed that the home has centralized heating system and ventilation. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke detector and carbon monoxide detector. There is a working telephone in the facility and the phone number is (408) 605-5571. All toxins are inaccessible to children. The home is free of hazardous materials. Licensee states there are no weapons in the home. LPA observed no pets in the home. LPA observed no bodies of water. The outside area is fully fenced. CPR and First Aid expire in 09/2021. Applicant has completed the 8 hours Preventive Health and Safety and Nutrition training. 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: Diana Stephenson
LICENSING EVALUATOR NAME: Ofelia Calivo
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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: SHAHBAZI, SHADIEH
FACILITY NUMBER: 434415614
VISIT DATE: 11/12/2021
NARRATIVE
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LPA discussed the safe sleep regulations with 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.

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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Shadieh Shahbazi.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Ofelia Calivo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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Document Has Been Signed on 11/12/2021 12:01 PM - It Cannot Be Edited


Created By: Ofelia Calivo On 11/12/2021 at 11:37 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: SHAHBAZI, SHADIEH
FACILITY NUMBER: 434415614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021

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: 12/10/2021
Plan of Correction
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Licenses states she will submit her current Mandated Reporter training certificate by December 10, 2021.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee's Pediatric First Aid and CPR training certtificates expired on 9/16/21. This poses a potential risk to the health, safety or personal rights to children in care.
POC Due Date: 12/10/2021
Plan of Correction
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Licensee will enroll and take the Pediatric First Aid and CPR training and upon completion, Licensee will submit proof of training by 12/10/21.
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: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021


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