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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414665
Report Date: 09/28/2022
Date Signed: 09/28/2022 03:34:53 PM

Document Has Been Signed on 09/28/2022 03:34 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KHAVARI, HALEHREZVANFACILITY NUMBER:
434414665
ADMINISTRATOR:KHAVARI, HALEHREZVANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 966-8004
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Khavari HalehrezvanTIME COMPLETED:
03:50 PM
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On 09/28/2022 at 1:15PM Licensing Program Analyst (LPA), Kaur, conducted an unannounced annual inspection and met with Licensee. The purpose of the inspection was explained and granted entry to the home by the Licensee. There are 7 children in care with Licensee and 1 helper. The Licensee rents this single-family home. Day Care Areas: the living room, dining area, master bedroom and small changing room by living room, and the backyard. Off Limit Areas are the garage and the other bedrooms. Hours of operations are Monday to Friday, 08:30 AM to 05:30 PM.

LPA and Licensee inspected the daycare areas for health and safety hazards. During the inspection, LPA observed the following: The daycare area is clean, orderly, and equipped with age-appropriate toys and equipment for the children. The home has adequate lighting and ventilation. The house has a working smoke alarm, carbon monoxide detector, fire extinguisher. First aid supplies are available for children. Per Licensee, there are no firearms, weapons, or pets in the home. LPA observed no pools, spas, or other bodies of water on the premises. The Licensee had posted all the required forms (i.e., License, Notification of Parent's Rights, Earthquake preparedness checklist, and Notification of Personal Rights).

LPA reviewed 3 children's records and staff records. LPA observed that the Licensee maintained records of each child accordingly; identification and emergency information, consent for medical treatment, and parent's rights were appropriately completed. The helper have maintained a record of immunization, mandated reporter training certification, and CPR & First Aids training are valid.

Incidentals 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

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.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Harsimran Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KHAVARI, HALEHREZVAN
FACILITY NUMBER: 434414665
VISIT DATE: 09/28/2022
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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 the 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.

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA reviewed AB 1207 with the Licensee. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at [email protected] and ask to be added to the email list for the updates.

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.



Based on today's inspection, no deficiencies were observed in the areas evaluated according the Title 22 Division 12 Ca. Code of Regulations. Exit interview was discussed with Licensee and her signature of this form acknowledges receipt of these documents.
This report and rights to comment were discussed. This report must be available in the facility for public review. Notice was given and must remain posted for 30 days. Facility was advised any additional questions to call Office, M-F, 8am-5pm, 408/324/2148 or 1-844-538-8766. Website: www.ccld.ca.gov
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Harsimran Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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