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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416801
Report Date: 12/21/2022
Date Signed: 12/21/2022 11:27:30 AM

Document Has Been Signed on 12/21/2022 11:27 AM - 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:MIRILAVASANI, HENGAMEHFACILITY NUMBER:
434416801
ADMINISTRATOR:HENGAMEH, MIRILAVASIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 806-7181
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/21/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Hengameh "Heather" MirilavasaniTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Cortney Nelson, met with Applicant, Hengameh "Heather" Mirilavasani, for announced change of location pre-licensing inspection. The purpose of today's inspection is to ensure the home is in compliance with Title 22 California Code of Regulations. Upon arrival, LPA was admitted into the home by Applicant and toured inside and outside of the family child care home (FCCH).

Applicant states that there are no other adults over the age of 18 residing in the home. LPA advised that any additional adults must be fingerprinted before initial presence in the home. The hours of operation for the FCCH will be Monday-Friday 8:00AM-5:00PM and the working phone on the premises will be the Applicants cell phone. The Applicant is planning to serve food prepared at the FCCH, however is not planning to enroll into any food programs at this time. The Applicant has submitted proof of residency for the home and has submitted proof of current liability insurance. LPA advised Applicant to complete Affidavit Regarding Liability Insurance (LIC282) if she does not maintain liability insurance at any point while operating the FCCH. LPA observed all required postings near the entrance of the FCCH.

Applicant was reminded 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.

LPA observed fully charged 3A40BC fire extinguisher (last serviced: 10/2022), working smoke detector and carbon monoxide detector. Applicant was reminded that fire/emergency disaster drills should be completed every 6 months. All cleaning compounds, poisons, medications, and other similar items are stored inaccessible to children. Applicant states that she does not plan to administer medication or Incidental Medical Services (IMS) at her FCCH, but may consider it if a child does not have a severe allergy.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: MIRILAVASANI, HENGAMEH
FACILITY NUMBER: 434416801
VISIT DATE: 12/21/2022
NARRATIVE
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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.

LPA toured inside the home and observed adequate materials, toys, and play equipment for the children. The Applicant has nine (9) napping cots, four (4) pack and plays, five (5) high chairs and six (6) booster chairs available for children's use. Off limits inside of the home are: living room, master bedroom, master bathroom, and laundry room. The home is orderly and safe for day care children. There is a fireplace located in the main day care room that is properly screened and barricaded to be inaccessible to children. The Applicant states that the fireplace will not be used while children are in care. LPA advised the Applicant to consider a baby gate between the dining room and the kitchen to assist with keeping children in the on-limits areas of the home. The kitchen is considered on-limits for the children, however the living room next to it is not. Applicant states that there are no weapons or firearms in the home.

The outside area of the home was inspected today and observed to be fenced in and safe for day care children. The Applicant states that she has a play structure that should be installed on Monday (12/26) and LPA advised that it is securely fastened to the ground when installed. There is an AC unit located outside that LPA advised should be barricaded to be made inaccessible to children. LPA additionally advised that water fountain located outside is filled with rocks so it does not accumulate water. The Applicant additionally states that she has various outdoor toys, such as bikes, painting and gardening materials that are still located at her FCCH in Los Gatos. Off limits areas outside of the home include: detached garage, front yard, and everything outside of fenced space for children. The Applicant states that she plans to access the outside area through the door located in her living room. There were no outdoor bodies of water observed during todays inspection.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: MIRILAVASANI, HENGAMEH
FACILITY NUMBER: 434416801
VISIT DATE: 12/21/2022
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Applicant states that for discipline of the children, she will work with the parents to follow similar discipline strategies as the child is used to at home. Children may have guided time away from other children where a staff member can talk with the child about their behavior as most of the children in care are very young. The time staff talk with the children will be in line with their age, two minutes for a two year old for example.

The Applicant states that she is not planning to transport children and understands that she must be home 80% of the time the day care is in operation.

Exit interview conducted and report was reviewed with the Applicant, Hengameh "Heather" Mirilavasani.

LPA advised applicant that a large family child care home license will be issued pending manager review and completion of the following corrections:

-AC located outside should be made inaccessible to children
-Water fountain located outside filled with rocks
-Completion of 8 hours Preventative Health and Safety course
-Photographs submitted of playground structure installed with proper ground attachments and other outside play toys/equipment
-Advised consideration of baby gate between dining room and kitchen area, but not required
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC809 (FAS) - (06/04)
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