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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407418
Report Date: 06/15/2022
Date Signed: 06/15/2022 11:53:45 AM


Document Has Been Signed on 06/15/2022 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:KHAZENI, MANIJEH & BEYK, MOHAMMADFACILITY NUMBER:
434407418
ADMINISTRATOR:KHAZENI & BEYKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 736-6310
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:14CENSUS: 7DATE:
06/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Manijeh Khazeni & Mohammad BeykTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Mel Matos conducted an unannounced case management inspection and met with Manijeh Khazeni & Mohammed Beyk, Licensees. Purpose of today's inspection. Discuss an unusual incident that the Licensees self reported to the Department. LPA also observed one adult assistant (Esther Chang) and 7 preschool children in the backyard area of the home during today's inspection.

LPA discussed the Unusual Incident that the Licensees self reported to the Department with Manijeh during today's investigation. Manijeh states that an incident occurred on May 24, 2022 in which one preschool child (C1) reported that another preschool child (C2) had hit C1 while both children were playing in the backyard area on May 24, 2022. Manijeh states that she, her spouse, two adult assistants, and seven day care children were present in the backyard area on May 24, 2022.

Manijeh states that she investigated the incident, including speaking with both children and their respective parents, and concluded that it was a misunderstanding between both children.

No deficiencies issued as a result of the incident.

Notice of site visit was issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
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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