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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004683
Report Date: 04/12/2022
Date Signed: 04/12/2022 01:19:21 PM

Document Has Been Signed on 04/12/2022 01:19 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:JALALI, MOZHGANFACILITY NUMBER:
414004683
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Mozhgan JalaliTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Haydee Caliboso arrived at the facility at 9:50AM to conduct an unannounced annual inspection. LPA met with Mozhgan. Purpose of the inspection was explained. Present during the inspection were Licensee, 1 infant, 1 toddler age child. LPA observed that the program is operating within ratio on this day. Licensee stated she lives in the house partially, and all volunteers have been fingerprint cleared and vaccinated. Hours of operation are: M-F, 8:00AM – 5:00PM. Licensee provides breakfast and snacks daily. Parents in the program provide lunch daily. The facility was inspected today, indoors and outdoors for health and safety hazards.

Daycare areas: Kitchen area, dining room area, hallway bathroom, hallway bedroom #1, and outdoor area. During the inspection, Licensee stated she would like to add bedroom #2 to the areas of care. Bedroom#2 was observed to be clean with no health and safety hazard. LPA instructed the Licensee to submit updated facility sketch of the home.
Off Limit areas: Kitchen (pass through only to access backyard). LPA and Licensee inspected the entire day care area for health and safety hazards. LPA observed that off limit areas were properly locked and made inaccessible to the children in care. LPA observed carbon monoxide and smoke detector in the home are properly working. A fire extinguisher of size 2A10BC or bigger was also available in the home. First Aid kit is fully stocked and accessible. Per Licensee, there is no firearm or weapon in the home. Licensee stated there are no bodies of water. LPA observed fireplace in the home have been completely blocked off. Per Licensee, there are no children in care who needs medications while in care.
Cont. 809-C pg. 2
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JALALI, MOZHGAN
FACILITY NUMBER: 414004683
VISIT DATE: 04/12/2022
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LPA observed that the house is clean, in good repair, and free of hazards with proper temperature and ventilation. LPA observed that there is a variety of age appropriate toys, books and other learning material available in the home for the children in care. Per Licensee, discipline policy is redirection or communicate/modeling about positive behavior.

All posting requirements are met and posted at the dining room area. Licensee have First Aid CPR will expire 4/2024. At 10:35am LPA observed, emergency drill was last conducted 11 months ago and properly logged. LPA reminded that emergency drill must be conducted at least once every six months, properly logged, and available upon request. All required posting documents are posted and visible. LPA reviewed child’s files during today’s inspection. LPA observed all files are complete and up-do-date. LPA observed facility has record of names, addresses and telephone numbers of each child’s authorized representative. Each child's record contains the record immunization.

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 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.
Cont. 809-C pg. 3
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JALALI, MOZHGAN
FACILITY NUMBER: 414004683
VISIT DATE: 04/12/2022
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The Licensee was reminded about Mandated Reporter training available on the CCLD website. In addition to the AB1207 training must be completed every two years by all staff hired, a one-time General Training is also required. Training can be taken online at www.mandaterreporterca.com. LPA observed Mandated Report is in file and current.

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 (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

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 [email protected]. 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.

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. Exit interview conducted and report was reviewed with Mozhgan Jalali. Today’s report and notice of site visit will be sent to the Licensee by the end of the day on 4/12/22. Confirmation of receipt is required.

>No deficiencies were cited today under Title 22 Division 12 of the California Code of Regulations.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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