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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409227
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:27:07 PM

Document Has Been Signed on 06/20/2023 03:27 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:HOSSEINI, MITRAFACILITY NUMBER:
073409227
ADMINISTRATOR:HOSSEINI, MITRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 666-9965
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
06/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mitra HosseiniTIME COMPLETED:
04:10 PM
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On 06/20/2023 at 3:00 PM, Licensing Program Analyst (LPA) Christina Watts conducted a Case Management Inspection at Mitra Hosseini's large family home. LPA met with licensee and explained the purpose of this visit. During today's inspection, there were 6 children in care (3 infants and 3 preschool aged children) with 1 aide and licensee stated there were 6 children enrolled. All adults present have Criminal Record Clearance.

Licensee received a Type B citation on 05/18/2023 for Personnel Requirements. Licensee was unable to provide a current and up to date CPR/First Aid certificate while caring for children. During today's inspection, licensee provided a current and up to date CPR/First Aid certificate for both licensee and aide. LPA also provided technical assistance with information on licensee's profile.

During today's inspection, no deficiencies were cited.

Exit interview conducted and report was reviewed with the licensee, Mitra Hosseini. A notice of site visit was given and must remain posted for 30 consecutive days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Christina Watts
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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