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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376105058
Report Date: 05/21/2021
Date Signed: 05/21/2021 03:27:46 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:DOT TO DOTFACILITY NUMBER:
376105058
ADMINISTRATOR:MAHZAD (MAZI) IRANIFACILITY TYPE:
850
ADDRESS:5550 CARMEL MOUNTAIN ROAD #113TELEPHONE:
(858) 207-7949
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:109CENSUS: 0DATE:
05/21/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mazi IraniTIME COMPLETED:
03:15 PM
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On 05/21/2021 at 2:30pm, Licensing Program Analyst (LPA) Samantha Salunga met with Mahzad (Mazi) Irani (Applicant) and assigned Center Director, Adriana (Rivera) Rutherford. Due to COVID-19 state of emergency, this meeting was completed via video conferencing (Zoom). The purpose of today's meeting is to review LIC184C together and clarify anything that Applicant had questions on.

LPA reviewed entire application and observed that the following areas needed updating/correcting: LIC200A, LIC308, LIC309, Articles of Organization, LIC401, LIC500, LIC610, LIC999, director's packet, job descriptions, personnel policies, in-service training plan, parent handbook, Incidental Medical Services- Plan of Operation, admission agreement, list of furniture, daily schedule, sample menu, rental agreement and Applicant information. LPA discussed all areas in detail with Applicant and Director and she confirmed she will submit all discussed corrections to LPA no later than 06/18/2021.

A copy of this report was reviewed and will be e-mailed to Applicant and Director. LPA advised that a response to the email confirming receipt is to be received within twenty-four hours. This will act as her signature on today’s report.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Samantha SalungaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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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