434416390-9-21-2023-07-CC-MMOO-CVVTVC-20230921150341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416390
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:03:51 PM

Document Has Been Signed on 09/21/2023 03:03 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:	ADELI, HAMIDEH		FACILITY NUMBER:	434416390
ADMINISTRATOR:	ADELI, HAMIDEH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(669) 888-6847
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 11	CENSUS: 9	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:24 PM
MET WITH:	Hamideh Adeli		TIME COMPLETED:	03:20 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), Marilou Monico, conducted an unannounced Required - 1 Year Inspection. LPA met with Licensee, Hamideh Adeli, and explained to her the nature of today's visit. Also present in the home were licensee's adult assistant and nine (9) daycare children including four (4) infants and five (5) preschool age. All required posting materials were posted. The daycare is open Monday thru Friday from 7:00 AM to 6:00 PM. There are no active waivers or exceptions for this facility. The daycare is a one storey home with three (3) bedrooms and one (1) bath. Per Licensee, the adults that reside in the home are herself and her husband. Licensee's two children ages 6 years old and 20 months old also live in the home. LPA obtained a copy of current children's roster during the inspection. Fire/disaster drill was conducted on August 18, 2023. LPA observed a fully charged 3A40BC fire extinguisher and functioning smoke and carbon monoxide detectors. 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 Licensee, Hamideh Adeli, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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. Continuation on next pages:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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: ADELI, HAMIDEH	FACILITY NUMBER: 434416390
	VISIT DATE: 09/21/2023

NARRATIVE

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Off limit areas inside the home are: master bedroom and garage. LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible to children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (669) 888-6847. Off limit areas outdoor: locked storage shed. No bodies of water were observed.

LPA reviewed nine (9) children’s files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Individual Infant Sleeping Plan (LIC 9227), nap log, and Immunization Records. Licensee does not carry daycare insurance. LPA observed that all nine files that were reviewed are missing the Affidavit Regarding Liability Insurance (LIC 282).

LPA reviewed licensee's file and her helper's file. Licensee and her helper have immunizations in measles, pertussis, and flu. Licensee and her helper have current Mandated Reporter Training. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years. Licensee has current CPR/ First Aid certifications that expire on September 10, 2023.

LPA provided and 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 reminded 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 she registers all infant devices with the CPSC to be notified of any recalls on her purchased equipment.

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.

Continuation on next page:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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: ADELI, HAMIDEH	FACILITY NUMBER: 434416390
	VISIT DATE: 09/21/2023

NARRATIVE

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Licensee, Hamideh Adeli, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&R's) throughout California.

As a result of today's inspection, deficiency was cited on the following page:

Exit interview conducted and report was reviewed with Licensee, Hamideh Adeli.

During the exit interview, Hamideh, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2023 03:03 PM - It Cannot Be Edited

Created By: Marilou Monico On 09/21/2023 at 02:24 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: ADELI, HAMIDEH	FACILITY NUMBER: 434416390
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(m)(3)

A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. 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 in 9 out 9 children which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	By POC due date, licensee states she will submit proof of daycare insurance.

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:

Joel Segura

LICENSING EVALUATOR NAME:

Marilou Monico

LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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