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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197400845
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:58:43 PM


Document Has Been Signed on 12/21/2023 02:58 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:KHOSHBAKHSH, JACKLIN F.D.C.FACILITY NUMBER:
197400845
ADMINISTRATOR:KHOSHBAKHSH, JACKLINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 840-0738
CITY:LOS ANGELESSTATE: CAZIP CODE:
90036
CAPACITY:12CENSUS: 7DATE:
12/21/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Jacklin KhoshbakhshTIME COMPLETED:
03:15 PM
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 Licensing Program Analyst (LPA) Shushanik Safaryan and Licensing Program Manager Claudia Guangorena conducted an unannounced required 3-year inspection to the above facility on 12 /21/23 , at 12:10 pm. A COVID-19 risk assessment was conducted upon entry. Licensing staff met with Licensee, Jacklin Khoshbakhsh, to whom the reason for the visit was explained. Per Licensee, there are 7 children currently enrolled. There were 7 children and one adult (licensees’ assistant) present upon arrival. Four children were observed to be infants, only one infant was under 12 months. The licensee was observed to be operating within the license capacity limitations.
The licensee states that 3 adults and no children currently live in the home; names noted on Confidential Name List (LIC 811). All adults living in the home have obtained a criminal record clearance.
This is a 2 story house which consists of 4 bedrooms, 2 playrooms, 3 bathrooms, kitchen, dining, living room, laundry room and detached garage. (First floor: living room, dining room, kitchen, 1-bathroom, 2 playroom and second floor 4 bedrooms and 2 bathrooms),
Per licensee, areas off limits to children and parents include entire second floor .(4 bedrooms, 2 bathrooms), detached garage, kitchen .
Main care is provided in 2 playrooms, dining room, living room , bathroom located at the first floor and outdoor area at backyard of the house.
During this visit, all areas identified that are accessible for children to use were inspected for the safety, comfort, and cleanliness. Facility sketch was reviewed with Licensee . At 12 pm Licensee guided Licensing staff to the tour of the home. Licensing staff was toured starting from the living room, where Licensing staff observed 2 play yards and 4 cots. Licensing staff observed fireplace that was not barricaded and advise licensee to block it to prevent children’s access. Per licensee living room and dining room is only used for napping . Licensing staff toured the dining room and observed a dining table , chairs, buffet sideboard. Per licensee children don’t use dinning room unless it is necessary for more napping space. Licensing staff during the tour observed that kitchen have access from the dining room which was not barricaded and advised licensee to put the child safety gate to keep the kitchen off limit. Next licensing staff observed stairs to the second floor which was barricaded. Per licensee parents come from the side door through the gate straight to the playroom, where licensing staff observed toys for children. Next to the playroom kids have eating area where licensing staff observed 3 highchairs. Licensee was reminded highchairs can be used only for eating and cannot be used as a time out chair or for the discipline purposes.
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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Shushanik SafaryanTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KHOSHBAKHSH, JACKLIN F.D.C.
FACILITY NUMBER: 197400845
VISIT DATE: 12/21/2023
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Facility License, Emergency Disaster Plan, Parent’s Rights Poster, and Earthquake Preparedness Checklist were observed to be posted in the playroom area of the home. A current children’s roster was available for review.

There is telephone service via a cellphone that stays at the facility during operation hours. Hours of operation are Monday – Thursday , 08:00 am – 4:00 pm. Friday 08:00am - 01:00pm. Licensing staff observed an open face floor heater in the playroom which was accessible to the children .
Detergents, cleaning compounds, and medications were observed to be inaccessible to children. Per Licensee, there are no poisons in the home. Licensing staff advised that any poisons should be locked under key or combination lock. Licensee states that there are no firearms or weapons stored in the home.

The valve on the required 2-A-10-B-C fire extinguisher indicates fully charged and Licensing staff observed receipt with a purchase date of 12/17/23. Smoke and carbon monoxide detectors were tested and are operable.
All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Last drill documented was conducted on 11/07/2023.

The home is observed to be clean and orderly. There are first aid supplies available. There are age-appropriate toys available for children.
Per licensee, she does not provide food for children in care. Food is brought from the children’s homes, Licensing staff observed lunch boxes for the children in the play room area.

Currently, children are using the backyard for outdoor play time. Licensing staff observed that the outdoor yard has toys and other materials for children to play with. Licensing staff observed swimming pool in the back of the house. The back yard is fully fenced with a swimming pool that is enclosed with a five-foot rod iron fence with a gate that opens away from the swimming pool and self closes and self-latches. During the tour Licensing staff noticed that swimming pool gate has side door to access the swimming pool and door from the side was not self -latching and was barricaded by licensee which can be climbable and pose danger to the children in care. (Pictures were taken ) Licensing staff observed that gate on the side was not in the good repair and might be stretched and could pose immediate hazard to the health and safety of children in care .
Licensee understands to provide care and supervision all the time. Licensing staff observed refrigerator, outside which per licensee she uses occasionally. Licensee advised to put the child safety latch on the doors to make inaccessible to the children.
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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Shushanik SafaryanTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KHOSHBAKHSH, JACKLIN F.D.C.
FACILITY NUMBER: 197400845
VISIT DATE: 12/21/2023
NARRATIVE
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Staff and Licensee files were reviewed for the following: LIC 508- Criminal Record Statement, Proof of immunization's against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse. Pediatric First Aid expires 08/24 and CPR certification expires on 08/2024. Licensing staff advised licensee First Aid and CPR training must be taken in person with an EMSA approved vendor and renewed every 2 years .

Mandated Reporter Training for licensee and Licensee's assistant has been completed and expires on 08/27/2024. LPA reminded licensee to renew training every two years at www.mandatedreporterca.com.


LPA Shushanik observed that Licensee is missing proof of Measles immunization. Per licensee she had the vaccine but was not able to provide the proof.

Children’s records were reviewed for LIC 282-Affidavit Regarding Liability Insurance, Immunization's Records ,LIC 700- Identification and Emergency Information, LIC 627-Consent for Medical Treatment and LIC 995A- Notification of Parent`s Right`s . Licensing staff observed files to be complete.

Licensee states she is currently caring for 4 infants. LPA did not observe a sleeping log for each infant and LIC 9227 for one infant .

LPA created an LIC 857, Children’s Record Review, and LIC 811, Staff Record Review which documents staff and children’s files reviewed during this inspection.

Per licensee, there are no animals on the premises, none observed.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, and/or any other item that fall into these categories are not permitted in a family childcare facility



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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Shushanik SafaryanTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KHOSHBAKHSH, JACKLIN F.D.C.
FACILITY NUMBER: 197400845
VISIT DATE: 12/21/2023
NARRATIVE
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LPA Shushanik discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA Shushanik also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.



To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. (Use LIC624B for written report). The on Duty Worker is available for questions Monday through Friday at (323) 981-3350 from 8:00 AM - 5:00 PM.

Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.


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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Shushanik SafaryanTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KHOSHBAKHSH, JACKLIN F.D.C.
FACILITY NUMBER: 197400845
VISIT DATE: 12/21/2023
NARRATIVE
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During the exit interview, the Jacklin Khoshbakhsh confirmed that there are no Registered Sex Offenders living in the facility and LPA Shushanik completed the RSO profile in FAS.

Based on the Licensing staff observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.


Licensing staff informed licensee Jacklin Khoshbakhsh that this report dated 12/21/23 shall be posted for 30 consecutive days as there are immediate risk(s) to the health, safety, or personal rights of children in care.

Licensing staff informed licensee to provide a copy of this licensing report dated 12/21/23 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.


A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Jacklin Khoshbakhsh. Appeal Rights were issued and discussed.

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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Shushanik SafaryanTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/21/2023 02:58 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: KHOSHBAKHSH, JACKLIN F.D.C.
FACILITY NUMBER: 197400845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(5)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. (A)Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed swimming pool iron gate door from the side was not self latching and some iron rods were not in good condition that might be streched and a child can crawl under it which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Licensee will block the access to the swimming pool or will fix the door and the gate by POC date and will notify the LPA for POC visit.

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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Shushanik SafaryanTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 12/21/2023 02:58 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: KHOSHBAKHSH, JACKLIN F.D.C.
FACILITY NUMBER: 197400845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. Licensing staff observed children had an access to the kitchen and did not observe safety latches for sharp items, refrigerator outside did not have a safety latch to prevent children access which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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Licensing will put child safety latches on the refrigerator door and child safety gate to the kitchen from the dinning room side to prevent children access to the kitchen. Licensee will email photos to the LPA by POC date .
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review, the licensee did not comply with the section cited above. Licensing staff did not observe sleeping plan or log for the infants in care in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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Licensee will complete logs for the infants and email proof to the LPA by POC date .
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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Shushanik SafaryanTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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