Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426210319
Report Date: 06/28/2018
Date Signed 06/28/2018 12:08:55 PM

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:
06/28/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Behjat KhodarahmTIME COMPLETED:
12:15 PM
NARRATIVE
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An annual random was conducted by LPA S. Mendoza-Ceja who met with Licensee Behjat Khodarahm and her assistant Serina Placensia. The home was toured inside and outside. The home was observed to be clean and orderly. Licensee stated primary rooms designated for the day care children are the first room as you enter the home, the room on the left and the far room down the hall for napping. The rooms were observed to be appropriately furnished for children. The yard was also observed to be furnished appropriately with toys. Licensee stated there are no firearms, ammunition or bodies of water on the premises. LPA observed gate which is used to make the kitchen area inaccessible to children. There are three (3) 2A1BC Fire Extinguishers on the premises; however, there was no current purchase or service date attached. Licensee stated she did purchase one within the year, but could not find the receipt. LPA did inspect the three (3) fire extinguishers (gauges were green).
There is a smoke detector and carbon monoxide detector which were tested. The children’s records were reviewed. LPA reviewed “A Child Care Provider’s Guide to Safe to Sleep” handout with Licensee. .
Licensee and her assistant both have current CPR and First Aid (expires 02/06/2020).

LPA reviewed the requirement for care providers/employees, including volunteers to obtain immunization against Influenza, Pertussis, and Measles. Verification was reviewed for licensee and her assistant. Licensee and her assistant completed the AB 1207 Child Mandated Reporter Training.

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

The following Type B deficiency is cited according to CCR, Title 22 Division 12 in regards to the 2 A10 BC Fire Extinguisher. Appeal Rights Reviewed.

The "Notice of Site Visit" was posted at the visit.

FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISOR'S NAME: Deborah AjaoTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132 FAX 685-1820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2018
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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: KHODARAHM FCC AKA ANGEL FAMILY CHILD CARE
FACILITY NUMBER: 426210319
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2018
Section Cited
CCR
102417(g)(1)
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102417(g)(1) Fire extinguishers and smoke detectors shall meet State Fire Marshal standards.

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Please submit verification to Licensing for review by 06/29/2018.
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This requirement was not met as evidenced by the licensee's failure to have verification of the service or current purchase date of the 2 A10BC Fire Extinguisher which poses a risk to the health and safety of children 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: Deborah AjaoTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132 FAX 685-1820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2018
LIC809 (FAS) - (06/04)
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