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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409018
Report Date: 02/02/2022
Date Signed: 02/02/2022 11:42:33 AM

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:MOUSAVI NASAB, SEYEDE DELARAMFACILITY NUMBER:
073409018
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
02/02/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Delaram MousaviTIME COMPLETED:
12:00 PM
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On 2/2/22 Licensing Program Analyst (LPA) Monica Mathur conducted a Case Management inspection at Delaram Mousavi's family home. Licensee has applied for CAPACITY INCREASE from 8 to 14 children and also wants to add/change areas for in use and off limit.
Fire clearance was issued on 12/8/21 and licensee has met all Fire Department requirement. All CCLD documents and requirement have been met. Licensee understands that parents have to be notified and Parent Notification for Additional Children in care LIC9150 has to be maintained in child files. Licensee's spouse will be the additional helper in the home. Licensee understands the ratio requirements of large home.

Licensee want to make changes to in-use and off limit areas starting 2/7/22:
IN USE: NAP ROOM, add LIVING ROOM, fenced area of backyard to be accessed from the outside through left side yard gate.
OFF LIMIT: All other bedrooms, Kitchen, Dining, Master bath, Garage (fire dept did not give clearance for garage use), Concrete areas of backyard, Gazebo, Shed.
LPA inspected all areas of the home inside and outside. Licensee will move furniture out of the living room and convert it into a Play Room. Furniture will be moved into one of the off limit bedrooms over weekend. It was agreed another inspection will be conducted over the weekend (virtually) before children return on Monday 2/7/22.

Facility is approved for LARGE CHILDCARE HOME. New areas are approved for use.

Exit interview was conducted with Licensee, Delaram
NOTICE OF SITE VISIT WAS ISSUED.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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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