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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416155
Report Date: 07/13/2021
Date Signed: 07/13/2021 01:01:20 PM

Document Has Been Signed on 07/13/2021 01:01 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:CARASTAN, MEHRNAZFACILITY NUMBER:
434416155
ADMINISTRATOR:MEHRNAZ CARASTANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 705-0505
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
07/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mehrnaz CarastanTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janette Cruz and Licensing Program Manager (LPM), Diana Stephenson arrived at 10:am and met with Mehrnaz Carastan, Licensee, for an unannounced Required – 1 year annual inspection. LPA/LPM were granted access to the home by the Licensee. LPA/LPM observed seven children (3 infants and 4 preschool), Licensee's spouse, Doru Carastan, and Licensee's daughter, Halleh Akbhari were in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements during today's inspection. LPA/LPM observed the required postings, including the facility license, near the front entrance to the home. The home has a working telephone (925) 705-0505. Days and hours of operation are Monday - Friday from 7:00AM to 6:00 PM. The Licensee, her spouse, Doru Carastan and daughter, Halleh Akhbari, are the adults residing in the home. The Licensee's CPR and First Aid are current and expires on 07/2023.

LPA/LPM reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 06/11/21. The Licensee, Licensee's daughter have the required vaccinations (MMR, Tdap, & flu). The Licensee has a Mandated Reporter Training on file which expired on 05/05/21. LPA reviewed seven children's files and observed current and updated Identification and Emergency Information (LIC 700) and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. The Licensee states that a child will be isolated in the living room area if needed to because of illness or communicable disease.

Safe sleep updated: LPA discussed the new “Safe Sleep” regulations with the Licensee and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee.
REPORT CONTINUED ON FOLLOWING PAGE #2 - REPORT DATED 07/13/2021):
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2021
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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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: CARASTAN, MEHRNAZ
FACILITY NUMBER: 434416155
VISIT DATE: 07/13/2021
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 07/13/2021):
LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPA/LPM toured the indoor and outdoor areas of the home during today's inspection. LPA/LPM observed the home is clean, orderly, and safe for the day care children. LPA/ LPM observed that the home is tri-level and had a child-proof gate on each level of the home. Off limit areas inside the home (bottom level): garage and basement which includes bathroom and utility room. Off limit area (2nd level): the entire 2nd level, which includes master bedroom, and a loft/office. Off limit areas (1st level): bedroom 1, bedroom 2, and barricaded kitchen. Licensee uses the first level area as the main area for the day care. There are two barricaded fireplaces and no open face heaters inside the home. LPA/LPM observed that Licensee is building a deck under construction which Licensee states that will also be off-limits to children.

LPA/LPM observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does not have any weapons in the home. Licensee has one cat in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Any poisons are locked in the attached garage and inaccessible to the day care children. Licensee has current child care liability insurance (exp. 08/01/2021).

A review of staff records on July 13, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPAs also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or

REPORT CONTINUED ON FOLLOWING PAGE #3 - REPORT DATED 07/13/2021):
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
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: CARASTAN, MEHRNAZ
FACILITY NUMBER: 434416155
VISIT DATE: 07/13/2021
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 07/13/2021):

provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time without a qualified assistant present. The Licensee states that does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA and LPM conducted an exit interview with the Licensee and advised her a Type B deficiency is cited during today's inspection (See page LIC809-D).
A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2021 01:01 PM - It Cannot Be Edited


Created By: Janette Cruz On 07/13/2021 at 12:24 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CARASTAN, MEHRNAZ
FACILITY NUMBER: 434416155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2021
Section Cited
HSC
1596.8662(4)(b)(1)

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1596.8662 (4)(b)(1) On or before 03/30/18, a person who on 01/01/18 is a licensed child day care provider shall complete the mandated reporter training......every two years following the date on which she completed the initial mandated reporter training. This requirement is not met as evidenced by:
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Licensee will submit a mandated reporter training certificate for herself and her daughter by POC date 7/20/21.
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Based on observation, interviews and record reviews, Licensee's mandated reporter expired on 05/05/21 and daughter has no updated mandated reporter training certificate on file which poses a potential threat on health and safety of children.
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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:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2021


LIC809 (FAS) - (06/04)
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