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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409424
Report Date: 07/17/2019
Date Signed: 07/17/2019 11:54:36 AM

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:PARVIN, SHAHANEWASFACILITY NUMBER:
434409424
ADMINISTRATOR:PARVIN, SHAHANEWASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 239-0231
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:14CENSUS: 5DATE:
07/17/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Shahnewas ParvinTIME COMPLETED:
12:00 PM
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On 07/17/19 Licensing Program Analyst [LPA] Monica Mathur conducted an unannounced Plan of Correction [POC] inspection at Shahnewas parvin's Family Day Care Home. LPA met with Licensee, Shahnewas and explained the purpose of today's inspection.

Two Type A citations and Civil Penalties were issued on 07/09/19 during an unannounced annual/random inspection for:
102416(d)(1) Personnel Requirements: Adult working and supervising day care children, without obtaining criminal record clearances.
102417(g)(4) Operation of a Family Child Care Home: Cleaning products were placed in area accessible to children in care.

LPA inspected the family home and observed that all cleaning supplies were stored inaccessible to the children. Present in the home were Licensee, Assistant Helper and five children (one infant, three preschool age, one school age child). LPA also observed LIC9224 forms were signed by each child's authorized representative and filed. Notice of Site Visit and Facility Evaluation Report LIC809 issued on 07/09/19 was posted on the wall inside the home. Licensee stated she provided copies of the Report dated 07/09/19 to parents.

Deficiencies cited on 07/09/19 were corrected and a Clearance Letter was given to the Licensee. Exit Interview was conducted, where a copy of this report was reviewed, and signed by the Licensee, confirming receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
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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