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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020273
Report Date: 06/25/2021
Date Signed: 06/25/2021 04:07:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:GOUDARZI FAMILY CHILD CAREFACILITY NUMBER:
198020273
ADMINISTRATOR:FARKHONDEH GOUDARZIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
6573219884
CITY:WHITTIERSTATE: CAZIP CODE:
90601
CAPACITY:14CENSUS: 9DATE:
06/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Farkhondeh GoudarziTIME COMPLETED:
04:15 PM
NARRATIVE
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An unannounced Case Management Inspection was conducted on this day by Licensing Program Analyst (LPA) Alanna Gontarek to follow-up on information received by the Department on an incident dated 5/19/2021. LPA met with Licensee, Farkondeh Goudarzi who guided LPA on a tour of the facility.

LPA observed 9 children in care, and 2 staff on this date. LPA interviewed staff and children, reviewed children’s files, and noted observations. LPA went over Incident report with Licensee.

In regards to the Unusual Incident reported 6/16/2021, Whittier Police Department came to the daycare and interviewed licensee and staff during operating hours. Whittier Police Department stated Child #3’s authorized representative reported that Child #3 stated that Licensee danced naked with Child #3, and mentioned a “secret Rose Room,” and a “Mr. Snowball.”

Based on interviews conducted with staff and children, corroborating disclosures were made that there is no such "Secret Rose Room" or "Mr. Snowball." Multiple disclosures were made stating children wear costumes in the Play room over their own clothes, and no staff or children are naked, except in the restroom for their own privacy. Documentation reviewed and obtained were: Child's records, Facility Roster, Child Protective Services Report, and email correspondences. There were no children's personal rights violated at this time.

There was a deficiency cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1 in regards to the above mentioned Unusual Incident Report.

Exit interview conducted with Licensee's Assistant/Daughter Shiva Goudarzi. A copy of the Appeal Rights (LIC 9058 FAS 01/16) were given and explained. Licensee’s signature on this form acknowledges receipt of these rights.

A Confidential Names list (LIC811) was provided during this visit.
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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: GOUDARZI FAMILY CHILD CARE
FACILITY NUMBER: 198020273
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2021
Section Cited

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Reporting Requirements:
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). This requirement is not met as evidenced by:
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Licensee did not report Unusual Incident dated 5/19/2021, involving police coming to facility during operating hours, timely, and reported incident on 6/16/2021. This poses a potential health and safety risk to the 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: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GOUDARZI FAMILY CHILD CARE
FACILITY NUMBER: 198020273
VISIT DATE: 06/25/2021
NARRATIVE
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Notice of Site Visit has been posted (LIC9213). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. Copies of this report must be posted for 30 days in a visible location for the authorized representatives of children.






















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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3