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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100485
Report Date: 11/24/2020
Date Signed: 11/24/2020 02:49:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:FAKHRI, MUZHGAN FAMILY CHILD CAREFACILITY NUMBER:
376100485
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
11/24/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Muzhgan FakhriTIME COMPLETED:
02:45 PM
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On 11/24/20 at 2:15 PM Licensing Program Analyst (LPA) Keturah Lane, conducted an unannounced tele-inspection (COVID-19 State of Emergency) for a capacity increase with the applicant, Muzhgan Fakhri. Also present in the home at the time of the tele-inspection were applicant’s three children. LPA recently toured the two-story home for a relocation tele-inspection on 10/29/20. Applicant owns the home. The home appears to be large enough to comfortably accommodate 14 children. Fire clearance was received on 11/16/20. First Aid and CPR certifications expire on 8/25/21. Applicant and her husband meet immunization requirements and have both completed Mandated Reporter Training. Children’s records were reviewed and found to be in order. There were 3 children in care at the time of the tele-inspection.
Applicant will be using the following rooms for childcare: downstairs bedroom #1, downstairs bedroom #2 and downstairs bathroom. The following areas will be off limits: downstairs laundry room and entire second floor and are inaccessible through the use of door-knob covers and a gate to the stairway. The garage will also be off limits and is kept inaccessible through the use of a door-knob cover. The applicant has toys and equipment available. The home has a fenced backyard available for outdoor play as renovations have been completed.

No deficiencies are cited. No corrections are needed; a license for 14 will be issued effective upon final file review.
An exit interview was conducted with applicant. A Notice of Site Visit (LIC9213) and Appeal Rights (LIC9058) will be sent along with the report (LIC809) via e-mail to the Applicant. Applicant will confirm receipt of this report via e-mail and the reply of confirmation will serve as the signature acknowledging these rights. The Notice of Site Visit (LIC9213) must remain posted for 30 days.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Keturah LaneTELEPHONE: (619) 767-2223
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
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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