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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416540
Report Date: 12/16/2022
Date Signed: 12/16/2022 03:03:22 PM

Document Has Been Signed on 12/16/2022 03:03 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:NOORI, MASSI & SHAVAKH, DAVIDFACILITY NUMBER:
434416540
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
12/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Massi NooriTIME COMPLETED:
03:15 PM
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On December 16th, 2022 at 2pm Licensing Program Analyst (LPA) Kassandra Medrano met with applicant,
Massi Noori, and Adult Daughter, Shadi, for an announced pre-licensing inspection. Applicants live in a single family home. Home has 3 bedroom, 2bath. Hours of operation will be 7:30am-5pm, Monday-Friday. CHILD CARE AREA: Bedroom1, Bedrrom 2, Backyard Sunroom, living room, dinning room, bathroom 1. OFF LIMIT AREAS: Master bedroom, master bathroom, front yard, and garage. LPA inspected the entire home with the applicant for health and safety hazards. The house has proper temperature and ventilation. All toxic or dangerous materials are stored in cabinets with child protective locks installed making them inaccessible. There is a fireplace in day-care area, but is not in use. The house has a working telephone, fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Applicant has first aid supplies available. Applicant states that there are not a pets in home. There are a variety of age-appropriate toys available. As per the applicant, there are no firearms or weapons in the home. Applicant was informed that time outs cannot be any longer than one minute per age of the child and cannot exceed five minutes. The main form of communication will be communication, and redirection. LPA informed the applicant that emergency drills will be conducted at least once every six months and drills must be logged. Applicant's First Aid/CPR certificate is current. LPA discussed facility ratios and capacity with the applicant. The applicant was reminded there are no walkers, exersaucers, jumpers, bouncers and any similar items to be used for children in care and shall be made inaccessible. Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 with applicant 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 Entrance Checklist was provided to the applicant. LPA discussed the safe sleep regulations with applicant 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.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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: NOORI, MASSI & SHAVAKH, DAVID
FACILITY NUMBER: 434416540
VISIT DATE: 12/16/2022
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LPA also informed applicant 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. ((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 OR 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 (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.)) 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 licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe

Small Family Child Care Home License is recommended for approval and will be effective as of today, 12/16/2022.

Exit interview conducted and report was reviewed with the applicant, Massi.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC809 (FAS) - (06/04)
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