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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416773
Report Date: 05/04/2022
Date Signed: 05/04/2022 12:00:21 PM

Document Has Been Signed on 05/04/2022 12:00 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:FARAHMAND POOR, ROZHINFACILITY NUMBER:
434416773
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/04/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rozhin Farahmand PoorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Marilou Monico met with Applicant, Rozhin Farahmand Poor, to conduct an announced prelicensing inspection at 10151 Miller Avenue, Cupertino, CA 95014. Applicant is the only adult residing in the home.

Days and hours of operation will be Monday - Friday from 8:00 AM to 5:30 PM. Applicant has completed her Preventative Health and Safety Child Care Training and a copy of the certification is on file. Applicant's CPR and First Aid certifications are current and expire on April 2024. Applicant completed Mandated Reporter Training on April 24, 2022. A copy of current TB test, flu, measles, and pertussis are on file. Applicant leases the home and lease agreement is on file. Applicant is planning to get daycare insurance once licensed.

LPA toured the indoor and outdoor areas during today's inspection. There are no stairs or fireplace units in the home. Off limit areas inside the home are: master bedroom and master bathroom. Off limit areas outdoor: garage and furnace closet. The home is clean and orderly, with heating/air conditioning, and ventilation for safety & comfort. There is sufficient toys, supplies, and equipment for the day care children both indoor/outdoor. LPA observed a fully charged 3A40BC fire extinguisher, working smoke and carbon monoxide detectors, fenced backyard, and no bodies of water. Applicant states that there are no weapons in the home.

Forms of discipline used by Applicant: talking to children and redirection. Cleaning products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.


Continuation on next pages:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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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: FARAHMAND POOR, ROZHIN
FACILITY NUMBER: 434416773
VISIT DATE: 05/04/2022
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Applicant understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

Applicant, Rozhin Farahmand Poor, 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, 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 discussed the requirements of Assembly Bill(AB) 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

LPA provided and reviewed the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA provided and discussed the safe sleep regulations with Applicant 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 Rozhin 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.


Continuation on next page:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
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: FARAHMAND POOR, ROZHIN
FACILITY NUMBER: 434416773
VISIT DATE: 05/04/2022
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APPLICANT STATES THAT SHE WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

PIN 22-02-CCP - Best Practices Related to the Provision of Incidental Medical Services in Child Care Center and Family Care Homes was provided to Applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the Applicant, Rozhin Farahmand Poor, and advised her that the following items need to be completed prior to approval of a Small Family Child Care Home License:

1) Photo of barricaded or screened air-conditioning unit located in the backyard
2) Photos showing that the furnace closet and master bedroom are inaccessible to children
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
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