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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422559
Report Date: 04/11/2024
Date Signed: 04/11/2024 09:56:32 AM

Document Has Been Signed on 04/11/2024 09:56 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SHAFIEI, MEHDIFACILITY NUMBER:
013422559
ADMINISTRATOR/
DIRECTOR:		SHAFIEI, MEHDIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 926-7745
CITY:OAKLANDSTATE: CAZIP CODE:
94618
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
04/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:SHAFIEI, MEHDITIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On April 11, 2024 at 8:30 AM Licensing Program Analyst (LPA) Nyeesha Blount conducted an unannounced case management visit to Amend complaint investigation report dated 3/15/24. Present during the inspection were Licensee Shafiei, Medhi and wife,(5) preschool children, (2) assistants.


No Deficiencies were cited during today's inspection.

Report was not reviewed Licensee Declined. Notice of site visit was given and appeal rights.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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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