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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416773
Report Date: 02/26/2025
Date Signed: 02/26/2025 05:12:46 PM

Document Has Been Signed on 02/26/2025 05:12 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:FARAHMAND POOR, ROZHINFACILITY NUMBER:
434416773
ADMINISTRATOR/
DIRECTOR:		ROZHIN, FARAHMAND POORFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 251-6021
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
02/26/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:04 PM
MET WITH:Rozhin Farahmand PoorTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
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On February 26, 2025 at 2:04 PM, Licensing Program Analyst (LPA), Marilou Monico, made an unannounced Annual Random inspection. LPA met with Licensee, Rozhin Farahmand Poor, and explained to her the nature of today's inspection. LPA was granted access to the home by the Licensee. The Licensee received the Entrance Checklist (LIC 126). Also present in the home were six (6) daycare children: 3 infants and 3 preschool age. LPA observed all required postings. 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. Licensee stated that she has a helper (S1) who started today. S1 does not have fingerprint clearances. Civil penalty of $100.00 was assessed.

LPA obtained a copy of current children's roster. Fire/disaster drill was completed on February 4, 2025. LPA observed a fully charged 3A40BC fire extinguisher and functioning smoke and carbon monoxide detectors. Licensee stated 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, 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, 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: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: FARAHMAND POOR, ROZHIN
FACILITY NUMBER: 434416773
VISIT DATE: 02/26/2025
NARRATIVE
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Off limit areas inside 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. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. Off limit areas outside the home: garage and furnace closet. There were no bodies of water 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), sleep log for children under 2 years old, and Immunization Records. C3 is missing Immunization Records.

Licensee has the required immunizations (measles, pertussis, and flu), Pediatric CPR/First Aid certifications with an expiration date of March 8, 2026. Licensee's Mandated Reporter Training for Child Care Providers was completed on April 24, 2024. LPA reminded licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

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.

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 pages:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: FARAHMAND POOR, ROZHIN
FACILITY NUMBER: 434416773
VISIT DATE: 02/26/2025
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Licensee, Rozhin Farahmand Poor, was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Exit interview conducted and the report was reviewed with Licensee, Rozhin Farahmand Poor.

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

As a result of this inspection, Type A and Type B deficiencies were cited on the next pages.

Assembly Bill (AB) 633 was provided and discussed with Licensee. LPA informed the Licensee to provide a copy of this licensing report dated February 26, 2025 that documents a Type A citation to parents/guardians of all children currently enrolled no later than the next business day or the next day the children are in care, and to parents/guardians of any newly enrolled children for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224) must be placed in the child's file for verification.

A Notice of Site Visit was given to Licensee, Rozhin Farahmand Poor, and must remain posted for 30 days.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
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Document Has Been Signed on 02/26/2025 05:12 PM - It Cannot Be Edited


Created By: Marilou Monico On 02/26/2025 at 04:22 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: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on licensee's statement, her adult helper (S1) started working in the home today. S1 does not have fingerprint clearances which poses an immediate health, safety or personal rights risk to persons in care.

Civil penalty of $100.00 was assessed.
POC Due Date: 02/27/2025
Plan of Correction
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Licensee submitted a written plan of correction during the inspection to schedule Livescan appointment for S1. S1 will return to work when fingerprint is cleared.

Deficiency corrected
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


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Document Has Been Signed on 02/26/2025 05:12 PM - It Cannot Be Edited


Created By: Marilou Monico On 02/26/2025 at 04:22 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: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, C3 is missing immunization records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Licensee states that she will submit immunization records for C3 by 03/12/25.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


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