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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416773
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:12:12 PM

Document Has Been Signed on 05/17/2023 03:12 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: 5CENSUS: 4DATE:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Rozhin Farahmand PoorTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Required - 1 Year Inspection and in response to licensee's request to increase the capacity from 8 to 14 children. LPA met with Licensee, Rozhin Faramand Poor, and explained to her the nature of today's visit. Also present in the home were five (5) children including three (3) infants and two (2) preschool age. All required posting materials were posted by the front door. The daycare is open Monday thru Friday from 8:00 AM to 5:30 PM. There are no active waivers or exceptions for this facility. The daycare is a one storey home with three bedrooms and two bathrooms. Per Licensee, she is the only adult residing in the home.

LPA observed a current children's roster (LIC9040). Copy of children's roster was obtained during the inspection. Fire/disaster drill was conducted on April 14, 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. Licensee states that she is not planning to administer medication at this time. 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

LPA reminded licensee 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.
Continuation on next pages:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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: FARAHMAND POOR, ROZHIN
FACILITY NUMBER: 434416773
VISIT DATE: 05/17/2023
NARRATIVE
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Off limit areas in the home: master bedroom and master bathroom. 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) 251-6021. Off limit areas outside the home: garage and furnace closet. No bodies of water were observed.

LPA reviewed five (5) 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), Affidavit Regarding Liability Insurance (LIC 282), Individual Infant Sleeping Plan (LIC 9227), and Immunization Records (PM 286/CDPH 286). Child #5 is missing LIC 9227 in the file. Child #2, #3, and #5 are missing LIC 282.

Licensee has immunization in measles, pertussis, and flu. Licensee's Mandated Reporter Training expires on April 24, 2024. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years. Licensee has current Pediatric CPR/First Aid certifications with an expiration date of April 23, 2024.

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.

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

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

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2023 03:12 PM - It Cannot Be Edited


Created By: Marilou Monico On 05/17/2023 at 02:19 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: FARAHMAND POOR, ROZHIN
FACILITY NUMBER: 434416773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(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
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Based on record review, the licensee did not comply with the section cited above in 3 out 5 children. Child #2, #3, and #5 are missing the Affidavit Regarding Liability Insurance LIC 282) in the file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Licensee states that she will copy of completed and signed form for the three children by 05/26/23.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Child #5 is missing the Individual Infant Sleeping Plan in the file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Licensee states she will submit completed form for Child #6 by 05/26/23.
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: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2023 03:12 PM - It Cannot Be Edited


Created By: Marilou Monico On 05/17/2023 at 02:19 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: FARAHMAND POOR, ROZHIN
FACILITY NUMBER: 434416773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 infants in care. Licensee is missing documentation that she's checking infants every 15 minutes when napping. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Licensee states she will submit nap log for the 3 infants by 05/26/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


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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: 05/17/2023
NARRATIVE
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Fire clearance for 14 children was granted on May 16, 2023.

As a result of today's inspection, deficiencies were cited on the following pages:

Exit interview conducted and report was reviewed with Rozhin Farahmand Poor, Licensee, and advised her that a license for a Large Family Child Care Home will be approved upon receipt of the Plan of Corrections for the deficiencies cited today.

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: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
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