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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412346
Report Date: 10/20/2022
Date Signed: 10/20/2022 01:01:40 PM


Document Has Been Signed on 10/20/2022 01:01 PM - 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:NEYNAVAEI, PERSHENGFACILITY NUMBER:
434412346
ADMINISTRATOR:NEYNAVAEI, PERSHENGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 431-9796
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:14CENSUS: 4DATE:
10/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Persheng NeynavaeiTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janette Cruz met with Persheng Neynavaei, LPA for an unannounced case management inspection. Based on record reviews, LPA learned that Licensee's assistant, Fariba Azad, who did not have Pediatric First Aid and CPR training, was left alone by Licensee to supervise four children (3 infants and 1 preschool) on 10/07/2022.

A deficiency was cited during today's inspection. See 809D.

Exit interview was conducted with Persheng Neynavaei, Licensee.

A Notice of Site Visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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 2


Document Has Been Signed on 10/20/2022 01:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: NEYNAVAEI, PERSHENG
FACILITY NUMBER: 434412346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited

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102416 (c) Personnel Requirements
The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
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Based on observation, interviews and record reviews, Licensee did not comply with the section cited above. Licensee did not obtain current Pediatric First aid and CPR training for adult assistant which poses a potential threat on health and safety of children.
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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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
LIC809 (FAS) - (06/04)
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