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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409008
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:51:03 PM

Document Has Been Signed on 06/07/2022 03:51 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:ZANDIYEH, PEGAHFACILITY NUMBER:
073409008
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
06/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:TIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) LPA Domantay and LPA Guirit arrived unannounced at the facility at 3:35pm on June 7, 2022 to conduct a case management visit to obtain updated contact phone number and email. LPAs attempted to ring door bell and knock on the door, but no answer. LPAs attempted to contact Licensee at 949-981-1785 but no answer. LPA Domantay left business card at licensees door.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Melissa Domantay
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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