Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426210319
Report Date: 04/16/2015 12:00:00 AM
Date Signed 04/16/2015 11:04:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:KHODARAHM FCC AKA ANGEL FAMILY CHILD CAREFACILITY NUMBER:
426210319
ADMINISTRATOR:BEHJAT KHODARAHMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 968-7838
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:14CENSUS: 5DATE:
04/16/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Behjat KhodarahmTIME COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
(1) Licensing Program Analyst (LPA) Ruth Gull made an unannounced RANDOM ANNUAL visit to the home. Met with Behjat Khodarahm, Licensee and explained the purpose of the visit. There were 5 children with an adult assistant present playing in the backyard. The licensee uses the living room, playroom and hall bathroom for the day care. Licensee also uses one bedroom for napping only. The other 2 bedrooms are off-limits via use of safety gates. The kitchen is off-limits via a safety gate. The attached garage is off-limits/locked. LPA did not observe any toxins/hazardous items accessible to children. There are age appropriate toys/equipment for the children. The regulation fire extinguisher was serviced on 3/19/15. Licensee is reminded to service/ purchase fire extinguisher annually. The smoke alarm was tested and found to be operational. LPA observed that all required documents were posted. The licensee uses the
backyard for the day care and it is totally enclosed by a fence with gates on either side of the house. There are age appropriate toys/equipment. There is a sandbox which was observed to be covered. There is a grass area and shaded area. The Licensee has a dry pond/fountain that is enclosed by an approximately two foot high fence with a gate. Licensee states that she keeps the fountain/pond dry and if it rains she has a pump to empty the water. Licensee's 1st AId/CPR certificates are valid until 3/29/16. Assistant's 1st Aid/CPR certificates are valid until 7/27/15. Children records were reviewed. Licensee states that she does not have any guns/weapons on the premises. Licensee states that she does not have a Foster Care License.

Licensee was reminded that it is her responsibility to know the regulations for Family Child Care Home which can be accessed online at www.ccld.ca.gov.

There were no deficiencies cited during today's visit.
SUPERVISOR'S NAME: Robert ChiricoTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Ruth GullTELEPHONE: (805) 895-4073
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2015
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1