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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197405723
Report Date: 04/02/2024
Date Signed: 04/02/2024 11:26:37 AM

Document Has Been Signed on 04/02/2024 11:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:HOSSEINKHAH FAMILY CHILD CAREFACILITY NUMBER:
197405723
ADMINISTRATOR:HOSSEINKHAH, ZAHRA JAMILFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 992-1212
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 12TOTAL ENROLLED CHILDREN: 10CENSUS: 5DATE:
04/02/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Zahra Jamil Hosseinkhah, LicenseeTIME COMPLETED:
11:45 AM
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On 04/02/2024 Licensing Program Analyst (LPA) Silva Garibyan conducted a site visit for the purpose of an Annual Random visit. The purpose of this visit is to ensure the standards for a Family Child Care Home are being met in accordance to California Tittle 22 Regulations and California Health and Safety Codes. Present during today's inspection was Licensee and five preschool age children. Days and hours of operation are 6:00 a.m. to 5:30 p.m., Monday through Friday and closed all major holidays. Licensee provides services for children newborn to 13 years old. Family members residing in the home include the licensee and licensee's husband/assistant. LPA toured the home inside and outside. Current facility sketch reviewed, and Licensee confirmed the following areas are used for the day care: bedroom 1 and bedroom 2, living/dining room, and the backyard. Applicant confirmed children nap in the living room/dining room area and the younger children nap in bedroom 1. Families access the home by the main entry door.
The following areas are currently OFF LIMITS: kitchen, bedroom 3, laundry room area, attached garage/storage room. LPA observed plastic door knob covers making the areas inaccessible.
The bathroom that children use is located outside the living room area. LPA inspected and observed the toilet, the sink, sink cabinet and shower area.
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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: HOSSEINKHAH FAMILY CHILD CARE
FACILITY NUMBER: 197405723
VISIT DATE: 04/02/2024
NARRATIVE
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There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible; locked in the laundry room top cabinet. The home was observed to have an enclosed front yard and back yard. LPA toured the backyard and found it to be fully fenced. LPA observed by the entrance the Parent Board with all necessary posting required ( Facility License (LIC 203), Emergency Disaster Plan (LIC610A), Notification of Parents' Rights Poster (PUB 394), If You see Something Say Something poster, Car Seat Safety poster). Child Care Facility Roster (LIC9040) was on file.

A review of the children's records was conducted and are found to have the following: LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC702, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization Card.

Licensee’s Mandated Reporter Training and CPR/First Aid was not available for review. Licensee agrees to complete the trainings and submit proof of completion.

A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.
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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: HOSSEINKHAH FAMILY CHILD CARE
FACILITY NUMBER: 197405723
VISIT DATE: 04/02/2024
NARRATIVE
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The living/dining room area were observed to have age appropriate toys. Three children size tables and 20 chairs were observed in the living room. 15 napping cots and three play yards were observed in Bedroom 1.
Licensee provides meals and snacks. LPA discuss food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date.
LPA observed licensee test the carbon monoxide and smoke detector in the living/dining room. The Fire Extinguisher (2-A:10-B:C) is mounted on the wall in the living room. All electrical outlets were observed to be covered. Per licensee, there are no weapons or firearms of any kind in the facility at this time. LPA did not observe any weapons.
To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

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 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. Page 3 of 4
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: HOSSEINKHAH FAMILY CHILD CARE
FACILITY NUMBER: 197405723
VISIT DATE: 04/02/2024
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LPA discussed the safe sleep regulations with licensee [or facility representative] 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 [or facility representative] 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 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: https://www.ada.gov/resources/child-care-centers/.
Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
During the exit interview, the licensee Zahra Jamil Hosseinkhah, confirmed that there are no Registered Sex Offenders living in the facility.
A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Zahra Jamil Hosseinkhah. Page 4 of 4
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2024 11:26 AM - It Cannot Be Edited


Created By: Silva Garibyan On 04/02/2024 at 10:41 AM
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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HOSSEINKHAH FAMILY CHILD CARE
FACILITY NUMBER: 197405723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, Licensee did not have proof of completing the Mandated Reporter AB1207 training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2024
Plan of Correction
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Per Licensee, proof of correction will be sent to LPA via email by 04/09/2024.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above Licensee did not have proof of completing the Pediatric CPR/First Aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2024
Plan of Correction
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Per Licensee, proof of correction will be sent to LPA via email by 04/09/2024.
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:Betty Bell
LICENSING EVALUATOR NAME:Silva Garibyan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024


LIC809 (FAS) - (06/04)
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