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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623657
Report Date: 07/08/2022
Date Signed: 07/08/2022 02:12:52 PM

Document Has Been Signed on 07/08/2022 02:12 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:NIKBEEN, MARZIAFACILITY NUMBER:
343623657
ADMINISTRATOR:NIKBEEN, MARZIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 835-2948
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
07/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Marzia NikbeenTIME COMPLETED:
02:30 PM
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At 12:50 p.m on Friday, July 8th, 2022, Licensing Program Analyst (LPA) Karyn Guerra met with Licensee, Marzia Nikbeen, for the purpose of an unannounced required - 1 year inspection. No children were in care during time of inspection. Hours of operation are 24 hours a day, 7 days a week. Licensee understands that children shall not be in care for greater than a 24 hour period. Off limit rooms consist of Master bedroom/bathroom, and garage. Licensee understands that child care children must not enter the off limits areas of the home. Licensee's daughter provided translation assistance.

All individuals subject to criminal background review have obtained a criminal record clearance. 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.

A health and safety inspection was conducted in all areas accessible to children. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated that there are no weapons nor poisons in the home. There is a gas fireplace that is not in use and has a covering to prevent access. Fire Drills have not been conducted nor documented.

LPA reviewed staff and children's files. Current in person EMSA CPR and First Aid certification was verified expiring 7/2023. LPA observed immunization records, emergency identification, signed parents rights, and consent for emergency medical treatment for enrolled child. Licensee was reminded that there shall be an individual infant sleeping plan for each infant up to 12 months and documentation of 15 minute napping checks.

report continued on 809-C.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: NIKBEEN, MARZIA
FACILITY NUMBER: 343623657
VISIT DATE: 07/08/2022
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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. Licensee understands that there shall be a crib or play yard for each infant who cannot climb out of a crib or play yard.

This provider is not currently providing Incidental Medical Services IMS services to children in care. 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: https://www.ada.gov/childqanda.htm.

A staff interview was conducted with the Licensee. The department's inspection authority was discussed. Annual fees are current. LPA provided the Child Care Advocates Program email address: [email protected], so the licensee can request to be added to the distribution list to receive Quarterly Updates.

Title 22 deficiencies are cited on the subsequent pages of this report. Appeal rights were provided. Exit interview conducted and report was reviewed with the licensee, Marzia Nikbeen. A Notice of Site Visit was given and must remain posted for 30 days. 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/inspection-process.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
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Document Has Been Signed on 07/08/2022 02:12 PM - It Cannot Be Edited


Created By: Karyn Guerra On 07/08/2022 at 02:04 PM
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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: NIKBEEN, MARZIA
FACILITY NUMBER: 343623657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as there is an infant under 12 months enrolled in care and LPA did not observe a crib or play yard at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will provide proof of purchase by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Seychelle De Luca
LICENSING EVALUATOR NAME:Karyn Guerra
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022


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