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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313893
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:01:30 PM

Document Has Been Signed on 05/15/2023 02:01 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MIRFATTAHI, SEYEDEH ZAHRAFACILITY NUMBER:
304313893
ADMINISTRATOR:MIRFATTAHI, SEYEDEH ZAHRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
9495454057
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
05/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:MIRFATTAHI, SEYEDEH ZAHRATIME COMPLETED:
12:00 PM
NARRATIVE
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 A Case Management inspection was conducted at the facility by Licensing Program Analyst (LPA) Mrs. Bootorabi. LPA was greeted by licensee Zahra Mirfattahi. Upon entry LPA did not observed the Notice of Site Visit from 5/5/2023. LPA consulted the licensee at entry. The licensee retrieved the notice of site visit from a table underneath documents from behind the door. Licensee then posted the NOS on the door again.

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, 2 adults including the licensee and 1 minor child live in the facility. The licensee was reminded that any individuals 18 years or older must have a background check clearance. During the visit the licensee was in compliance.

A census was taken upon entry.


Adults working with children: 2
Other Adults: 0
Infants(0-24m): 2
Preschool Age Children: 2
The licensee was operating within the licensed capacity as specified on the license.

During today’s inspection, LPA observed one child in a high chair, 1 child watching television, another child playing and an infant being held by assistant #1. The area of care upon entry consist of the living room.

A facility tour was conducted with the licensee Zahra. The kitchen was observed to have cooked food on the stove and licensee stated that it was the lunch of the children. Licensee had a mini fridge in the kitchen and stated that it contained the food for the children.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MIRFATTAHI, SEYEDEH ZAHRA
FACILITY NUMBER: 304313893
VISIT DATE: 05/15/2023
NARRATIVE
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The LPA and licensee toured the bathroom next. The License stated that none of the children use the bathroom at this time. Next LPA and licensee toured the back yard. The backyards had tall weeds and grass, a swing set that could pose a danger to children currently in care (not age appropriate), other large items were observed on the swing set that could pose a danger to children in care items such as toys stacked on each other that were observed to be sun damaged. Underneath the play set LPA observed a dog house with a large dog. The dog was loose and LPA did not feel safe to tour the rest of the backyard. The grounds around the swing set had dog feces. The backyard is not sanitary or safe for children at this time.

Indoor area contained a baby gate that prevents children from going to the front door. The gate is broken and poses a risk to children in care. The living room also contained a broken play yard. A consultation was provided to the licensee.

Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections.

The LPA requested to review the LIC 9224 for the citations on 5/5/2023. The licensee demonstrated 4 of 6 LIC 9224 forms.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed, and Sited at the time of the visit.



102417(b) Operation of a Family Child Care Home

1596.817 Notice of Site Visit

An exit interview was conducted with licensee. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First-level appeals should be sent to the regional manager at the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2023 02:01 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 05/15/2023 at 10:52 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MIRFATTAHI, SEYEDEH ZAHRA
FACILITY NUMBER: 304313893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2023
Section Cited
HSC
102417(b)

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The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.
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Licensee stated the backyard will be cleaned today.
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Based on observations and licensee interview the backyard poses a poteential health & safety risk to persons in care. LPA observed dog feces, and unsanitary back yard.
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Type B
05/15/2023
Section Cited
CCR1596.817

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Notice of Site Visit must be posted for 30 consecutive days
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Licensee reposted the NOS.
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Based on observations and licensee interview the NOS was not posted which is poteential health & safety risk to persons in care.
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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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


LIC809 (FAS) - (06/04)
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