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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313893
Report Date: 08/18/2023
Date Signed: 08/21/2023 12:59:45 PM

Document Has Been Signed on 08/21/2023 12:59 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MIRFATTAHI, SEYEDEH ZAHRAFACILITY NUMBER:
304313893
ADMINISTRATOR:MIRFATTAHI, SEYEDEH ZAHRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 545-4057
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
08/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Zahra MirfattahiTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted a Plan of Corrections ( POC0 visit on 8/18/2023. The purpose of the visit was to clear deficiencies and it was stated to the licensee upon entry.

LPA toured the home upon arrival. Census was taken 5 children to 1 adult.


LPA consulted the licensee regarding the backyard having items that can pose a danger to children. Licensee stated that she is not using the backyard at this time due to the weather being to hot.

LPA requested to reviewed LIC 9224. Licensee did not clear the deficiency and did not have a completed LIC9224 for children in care. A consultation was provided.

LPA observed two baby bassinets in the areas of care. The licensee stated she was not using them and is in the process of cleaning out a room she uses for storage. There are no infants present in care and the items were observed to be full of other STUFF. LPA later observed licensee removing them from the area of care.

Licensee was reminded that all adults 18 and over living or working in the home, 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 the 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.

The facility was not in compliance. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: CCR 102419(5)(g)
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2023
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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Document Has Been Signed on 08/21/2023 12:59 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 08/18/2023 at 03:02 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MIRFATTAHI, SEYEDEH ZAHRA
FACILITY NUMBER: 304313893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
102419(5)(g)

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102419 (5)(g) ...parents must be provided copies of the following or failure to comply with this will result in a citation...Obtain parental signature and date .. LIC 9224... as receipts in the child’s file that the parents have received copies.
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LPA could not longer complete visit.
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Based on LPA's record review the licensee did not comply by means of not having LIC9224 with parents names, and missing LIC 9224 for past Type A deficiencies LPAs provided a consultation.
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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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023


LIC809 (FAS) - (06/04)
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