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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405150
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:17:00 AM


Document Has Been Signed on 07/21/2022 11:17 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:SAFABAKHSH,KIARASH & MORTEZA & ZABAHIYAN, SEDIGHEHFACILITY NUMBER:
073405150
ADMINISTRATOR:SAFABKHSH, KIARASH KFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 890-2061
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:14CENSUS: 6DATE:
07/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kiarash SafabkhshTIME COMPLETED:
11:30 AM
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On 7/21/22, at 10:15AM,Licensing Program Analyst (LPA) Catherine Fernandes arrived on a case management inspection and met with Kiarash Safabkhsh. Present in care were three infants and three preschoolers with two additional fingerprint cleared staff members.

LPA Fernandes toured the home and provided a list of documents needed for the facility file.



Please send updated copies to CCL:
-Immunization for all adults living in the home
- updated LIC610A
- Copy Orientation certificate
- Copy of control of property


Exit interview conducted
report, appeal rights and Notice of site provided.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine FernandesTELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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