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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408266
Report Date: 05/19/2023
Date Signed: 05/19/2023 12:42:10 PM


Document Has Been Signed on 05/19/2023 12:42 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:GOLESTANFACILITY NUMBER:
073408266
ADMINISTRATOR:DELAVARIAN, MICHKAFACILITY TYPE:
850
ADDRESS:320 SAN CARLOS AVETELEPHONE:
(510) 704-8541
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:45CENSUS: 20DATE:
05/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:AFKARY, PEGAHTIME COMPLETED:
01:00 PM
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On 05/19/2023 at 11:30AM Licensing Program Analyst (LPA) Nyeesha Blount conducted a unannounced Case management for Lead Testing/ exceedance at Golestan. LPA met with Director Afkary, Pegah and explained the purpose of today's inspection.

LPA toured the facility for a health and safety check. The water fountain outside in the front entrance exceeded the acceptable amount of lead allowed in a child care center. The director stated that facility has not used drinking fountain outdoor since 10/2018 and will be permanently ceased. the drinking fountain are inaccessible to children in care.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the director Afkary, Pegah..
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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Document Has Been Signed on 05/19/2023 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: GOLESTAN
FACILITY NUMBER: 073408266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited

101700.3

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Licensee shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.
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The facility will permanently cease Drinking fountain outdoor.Director stated they will cap off faucets and handles. POC date of June 19, 2023.
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Based on record review the licensee did not comply with the section cited above as there was a drinking foutain outdoor had a lead exceedance, which poses a potential Health and 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: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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