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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408266
Report Date: 05/19/2023
Date Signed: 05/19/2023 12:42:10 PM

Document Has Been Signed on 05/19/2023 12:42 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:GOLESTANFACILITY NUMBER:
073408266
ADMINISTRATOR:DELAVARIAN, MICHKAFACILITY TYPE:
850
ADDRESS:320 SAN CARLOS AVETELEPHONE:
(510) 704-8541
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 20DATE:
05/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:AFKARY, PEGAHTIME COMPLETED:
01:00 PM
NARRATIVE
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On 05/19/2023 at 11:30AM Licensing Program Analyst (LPA) Nyeesha Blount conducted a unannounced Case management for Lead Testing/ exceedance at Golestan. LPA met with Director Afkary, Pegah and explained the purpose of today's inspection.

LPA toured the facility for a health and safety check. The water fountain outside in the front entrance exceeded the acceptable amount of lead allowed in a child care center. The director stated that facility has not used drinking fountain outdoor since 10/2018 and will be permanently ceased. the drinking fountain are inaccessible to children in care.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the director Afkary, Pegah..
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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Document Has Been Signed on 05/19/2023 12:42 PM - It Cannot Be Edited


Created By: Nyeesha Blount On 05/19/2023 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: GOLESTAN
FACILITY NUMBER: 073408266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited

101700.3

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Licensee shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.
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The facility will permanently cease Drinking fountain outdoor.Director stated they will cap off faucets and handles. POC date of June 19, 2023.
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Based on record review the licensee did not comply with the section cited above as there was a drinking foutain outdoor had a lead exceedance, which poses a potential Health and Safety risk to persons in care.
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
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