<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314013
Report Date: 08/10/2022
Date Signed: 08/10/2022 02:55:02 PM

Document Has Been Signed on 08/10/2022 02:55 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MIRZA MEHDI MOMAYEZI, MINAFACILITY NUMBER:
304314013
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
08/10/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee Ms. Mirza Mehdi Momayezi, Mina TIME COMPLETED:
03:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A Case Management (Licensee initiated) inspection for a change in capacity was conducted at the facility by Licensing Program Analyst (LPA), Desai, Ketki. LPA observed licensee Ms. Mirza, Mehdi Momayedi, Mina caring for 1 Infant (1 year old) and 3 Preschool age children between the ages of 2-4 years old. Licensee has been a care provider for a Small Family child care home since February 2016, qualifying her to be a Large Family child care provider. Licensee relocated to this address in April 2022.

Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are two adults residing in the facility.

Licensee stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. She was reminded if changes to notify the licensing office.

Per Licensee, operation hours will be Monday to Friday, 7.00 AM to 5.00 PM, care and supervision shall be provided to children ages 3 months to 5 years of age (Infants to Preschool age children only).

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. This is a two story town home condo with 3 bedrooms, 2 and a half bathroom, living area, dining area, kitchen, Den area, laundry room, backyard with an attached garage.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone is the primary contact phone. Ventilation and heating. There is central air and heat in the home. Home has ceiling vents for air flow. The A/C unit is not accessible. (1)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MIRZA MEHDI MOMAYEZI, MINA
FACILITY NUMBER: 304314013
VISIT DATE: 08/10/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children.

Off Limit areas: Licensee has designated the entire second level of the home: three bedrooms and two full bathrooms as off limit areas, on the first level of the home, the attached garage/laundry room as off limit area. Garage is accessed from the laundry room and this door has a child safety lock installed making both the garage and laundry room inaccessible to children. Kitchen is open with all the cabinets and drawers with a child safety locks installed. The second level of the home is made inaccessible by a child safety gate on the bottom of the stairway. There is no Fire place or open heaters in the home.



Designated Day care area: Licensee continues to use the designated areas on the first level of the home for Day care activities (Living area, dining area, den, kitchen with one bathroom adjoining the laundry room for day care activities.) The children shall enter through the main door of the home leading to the living room the designated for Day care activities. Each room has age appropriate furniture along with educational and play activities for children.

Den area on the right side of the entrance door, now shall be used as an activity area and Infants nap in the living area and cribs are arranged on the side and Licensee is present in the same area , Toddlers and Preschool age children nap in the living area using cots. Linens are provided by the applicant and blankets are brought from home, washed on a weekly basis by the parents. Dining activities shall be held on the dining table. Infants/ Toddlers use high chairs which are arranged surrounding the dining table. Licensee continues to provides home cooked food to the enrolled children.

Infant care area was observed to have napping items, including changing mats/ high chairs, Infant items: diapers / wipes/ lotions and milk are provided by the parents. Mother's milk shall be labeled and stored appropriately. Per Licensee and the assistant the infants are not left unattended while they are sleeping.

Licensee provides Breakfast, AM/PM snacks, lunch if food is brought from home and these containers shall be labelled with their names by the parents and stored accordingly.

(2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MIRZA MEHDI MOMAYEZI, MINA
FACILITY NUMBER: 304314013
VISIT DATE: 08/10/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The bathroom is located adjoining the laundry room following a small passage area from the kitchen, children shall walk through the living area to access the designated bathroom. Licensee has small step stool and toddler toilet seat for the younger toddlers. There is no cabinets under the sink. The children's bathroom was observed to be safe and free of hazardous items.

LPA discussed the Safe Sleep practice with the Licensee Ms. Mirza Mehdi Momayezi, Mina



Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with applicant the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used if they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a T-shirt and not be too hot or too cold.
Licensee maintains the required LIC 9227 form and sleep log in the infant's file.

Hard copy and link of Child Care Providers Guide to Safe Sleep provided to licensee on this day: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

Outdoor activity area: Licensee now has designated the back yard for outdoor activities, it was observed to have concrete flooring and sufficient shade. Licensee has installed a child safety gate on the right side yard area, making it inaccessible to children, and a mesh fence surrounding the rose plants. Age appropriate toys are available for outdoor activities. There is an Emergency exit door at the end of the left yard and it remains locked (Latch has a lock installed)

There are no pets, firearms, weapons or bodies of water in the home. (3)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MIRZA MEHDI MOMAYEZI, MINA
FACILITY NUMBER: 304314013
VISIT DATE: 08/10/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The value on the 2A10 BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable. Licensee has mounted the Fire extinguisher on the side wall of the day care room. Smoke & Carbon Monoxide detectors are mounted on the ceiling of the passage area on the first and second level, including one of each installed in all the three bedrooms on the second level.

LPA verified there is a working telephone service (cellular service) in the home.

The licensee does have a current roster of children in care and the 4 records were reviewed on today's inspection, LPA reviewed the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance.

The licensee along with the assistant holds a valid Pediatric CPR/First Aid certification is valid through April 27th 2023 and have completed the required Mandated Reporter Child Abuse training.
Licensee also has conducted Emergency fire and earthquake drills, last drill conducted in June 2022.

LPA verified the Control of Property (Licensee is the owner of the home)

The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization's, Pediatric CPR/First Aid, and mandated reporter training.

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

OTHER INFORMATION AND FORMS PROVIDED:
Capacity Handout for a Large Family Child Care Home was provided and LIC 9150 was reviewed with the Licensee
(4)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MIRZA MEHDI MOMAYEZI, MINA
FACILITY NUMBER: 304314013
VISIT DATE: 08/10/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Fire inspection from Orange County Fire Authority Fire inspection services have granted the fire clearance with specific instruction where garage and the second level is not permitted for Day care.

LPA discussed the following items with the Licensee Ms. Mirza, Mehdi Momayezi, Mina during the Exit interview:

Criminal Record statement: Licensee Ms.Mirza, Mehdi Momayezi, Mina 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.

Safe Sleep : LPA discussed the safe sleep regulations with Licensee Ms. Mirza, Mehdi Momayezi, Mina & 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 of the Licensee Ms. Mirza, Mehdi Momayezi, Mina 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.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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 (USDOJ) 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.

Review of records to be maintained : LPA reviewed with Licensee Ms. Mirza, Mehdi Momayezi, Mina the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MIRZA MEHDI MOMAYEZI, MINA
FACILITY NUMBER: 304314013
VISIT DATE: 08/10/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Subscribe to CCLD important information
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important license- related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option

The facility was complying with Title 22 Regulations at the time of inspection.

LPA discussed the ratio for the Large Family Child Care home with the Licensee: Large Family Child Care Home, and with an assistant provider, may provide care for more than 12 and up to 14 children when one child is enrolled in and attending kindergarten (including transitional kindergarten) or elementary school, and another child is at least six years old, and no more than three infants are in care.

( Poster given to the Provider)


On today’s inspection each child was observed to have a safe, healthful and comfortable accommodation furnishing and equipment’s.

A license with the change in capacity for 12 children (Large Family Child care home) will be issued after final review, in the event additional requirements are needed, Licensee will be notified.


A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

A copy of this report and Appeal rights were presented to the Licensee Ms. Mirza Mehdi Momayezi, Mina.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6