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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415860
Report Date: 05/11/2023
Date Signed: 05/11/2023 04:14:10 PM

Document Has Been Signed on 05/11/2023 04:14 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:MAZLOOM, SEDIQUEFACILITY NUMBER:
444415860
ADMINISTRATOR:MAZLOOM, SEDIQUEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 656-1590
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
05/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Sedique MazloomTIME COMPLETED:
04:21 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Cortney Nelson and Ashley Lopez, met with Licensee, Seidque Mazloom, for an unannounced Required- 1 Year Inspection. LPA was granted access to the home by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were thirteen children (2 infants, 11 preschool-age), the Licensee, and two (2) assistants present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings and the hours of operation are Monday – Friday, 8:00AM-5:00PM.

The Licensee states that there are no additional adults living in the home.

Licensee 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 reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The last fire/disaster drill was conducted on 12/15/2022, which is compliant with the six-month requirement for homes. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke detector and carbon monoxide detector. Licensee states that she has a child in care who require Incidental Medical Services and medication is properly stored out of reach of children with the proper documentation. There are no weapons or firearms in the home.

This facility provides Incidental Medical Services- IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes, Section 102417. 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
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
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: MAZLOOM, SEDIQUE
FACILITY NUMBER: 444415860
VISIT DATE: 05/11/2023
NARRATIVE
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Indoor areas of the home were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Off-limits inside the home include: entire second story and attached garage. The Licensee has a waiver for a fireplace and LPAs observed that all conditions were met. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The Licensee has a working telephone in the home. Stairs are barricaded appropriately to keep day care children safe. LPAs advised that cleaning materials, shampoos, nail polish, and other similar items located in the kitchen and bathroom cabinets must be relocated to be made inaccessible to children.

The backyard area of the home was inspected and observed to be fenced in. LPA observed sufficient play-equipment and supplies for the children that are in good condition and age-appropriate. The Licensee has chickens and rabbits that are caged and safe for children. Off-limit areas outside of home include: both side yard areas and area beyond the fenced area for children. The Licensee has a hot tub that is located in the off-limits area that has proper cover and locks.

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.

Children and staff files were reviewed and all required documents were present. The Licensee has CPR/First-Aid that expires 3/13/2024 and Mandated Reporter Training that expires on 6/14/2024 and LPA reminded that training must be renewed by all staff every 2 years.

Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Sedique Mazloom.

As a result of todays inspection, deficiencies were cited, see LIC809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/11/2023 04:14 PM - It Cannot Be Edited


Created By: Cortney Nelson On 05/11/2023 at 03:35 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: MAZLOOM, SEDIQUE
FACILITY NUMBER: 444415860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above for cabinets located in the kitchen and bathroom where potentially dangerous items are located accessible to children, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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The Licensee will submit photos of items relocated or lock installed for the cabinets to the Department by 5/18/2023.
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as LPAs observed infants sleeping in a bedroom with the door closed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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The Licensee will submit written declaration of how infants will nap in her family child care home and meet the requirements for infant safe sleep.
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:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/11/2023 04:14 PM - It Cannot Be Edited


Created By: Cortney Nelson On 05/11/2023 at 03:35 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: MAZLOOM, SEDIQUE
FACILITY NUMBER: 444415860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.5(d)(2)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as 13 children are in care today and child enrolled into kindergarten is not currently attending, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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The Licensee will submit written attestation of requirements needed to care for more than 12 children in a large family child care home and submit to the Department by 5/18/2023.
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:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023


LIC809 (FAS) - (06/04)
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