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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409227
Report Date: 06/12/2026
Date Signed: 06/12/2026 04:27:08 PM

Document Has Been Signed on 06/12/2026 04:27 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:HOSSEINI, MITRAFACILITY NUMBER:
073409227
ADMINISTRATOR/
DIRECTOR:		HOSSEINI, MITRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 666-9965
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 9DATE:
06/12/2026
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Mitra HosseiniTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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On 06/12/2026 at 2:05 PM, Licensing Program Analyst (LPA) Liam Bucsko and Licensing Program Manager (LPM) Sherelle Johnson conducted an Unannounced Required Inspection for Mitra Hosseini's Large Family Child Care Home. LPA met with Licensee was guided on a tour of the facility. During today's inspection, there were 9 children in care (7 preschoolers and 2 infants) and 10 children enrolled. Family members residing in the home are Licensee, Licensee's husband, and Licensee's mother. All adults living in the home have Criminal Record Clearance. Facility hours of operations are Monday - Friday 7:00 AM - 5:30 PM.

This is a two story home which consists of 3 bedrooms, 2 1/2 bathrooms, kitchen/dining room, living room, family room, laundry room, attached garage, and backyard with swimming pool.

ON-LIMIT: Living room, family room, kitchen/dining room, first floor half bathroom, and backyard.

OFF-LIMIT: Entire second floor consisting of 3 bedrooms and 2 bathrooms, laundry room, and attached garage.

The LPA toured all areas used by children during this visit.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and central heating system for safety and comfort. There were safe toys, play equipment and materials observed for children. There are stairs in the home that are made inaccessible for children in care. There is a working telephone in the home. Detergents, poisons, cleaning compounds, medications, and other items which can pose a danger to children are made inaccessible in the home.

Per licensee, there are no weapons or firearms in the home. Licensee has an up to code 3A40BC fire extinguisher and working smoke/carbon monoxide detector on the premises.

NAME OF LICENSING PROGRAM MANAGER: Sherelle Johnson
NAME OF LICENSING PROGRAM ANALYST: Liam Bucsko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/12/2026 04:27 PM - It Cannot Be Edited


Created By: Liam Bucsko On 06/12/2026 at 03:35 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: HOSSEINI, MITRA
FACILITY NUMBER: 073409227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(1)(B)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (1) The swimming pool shall be equipped with, at minimum, the following drowning prevention safety features: (B) In addition to the characteristics described in subparagraph (A), at least one of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the swimming pool located at the facility did not possess an approved safety pool cover or an alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Licensee shall come into compliance and a POC inspection will be completed within the POC timeframe.
Type B
Section Cited
HSC
1596.814(a)(2)(A)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (A) A life ring with a minimum exterior diameter of 17 inches and labeled as approved by the United States Coast Guard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the swimming pool at the facility did not possess a compliant life ring which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Licensee shall come into compliance and a POC inspection will be completed within the POC timeframe.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sherelle Johnson
NAME OF LICENSING PROGRAM MANAGER:
Liam Bucsko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2026 04:27 PM - It Cannot Be Edited


Created By: Liam Bucsko On 06/12/2026 at 03:35 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: HOSSEINI, MITRA
FACILITY NUMBER: 073409227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(2)(B)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (B) A rescue pole with a body hook and a minimum fixed length of 12 feet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the facility did not possess a compliant rescue pole which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Licensee shall come into compliance and a POC inspection will be completed within the POC timeframe.
Type B
Section Cited
HSC
1596.814(a)(3)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (3) A licensee shall perform a daily inspection of the drowning prevention safety features and safety equipment before opening the facility and maintain a log of the inspections to be provided to the department upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the licensee did not possess a daily inspection log of the facility swimming pool which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Licensee shall come into compliance and a POC inspection will be completed within the POC timeframe.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sherelle Johnson
NAME OF LICENSING PROGRAM MANAGER:
Liam Bucsko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2026


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 06/12/2026 04:27 PM - It Cannot Be Edited


Created By: Liam Bucsko On 06/12/2026 at 03:35 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: HOSSEINI, MITRA
FACILITY NUMBER: 073409227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as one employee did not possess documented proof of completed mandated reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Licensee shall come into compliance and a POC inspection will be completed within the POC timeframe.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as one employee did not possess documentation of required immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Licensee shall come into compliance and a POC inspection will be completed within the POC timeframe.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sherelle Johnson
NAME OF LICENSING PROGRAM MANAGER:
Liam Bucsko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2026


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 06/12/2026 04:27 PM - It Cannot Be Edited


Created By: Liam Bucsko On 06/12/2026 at 03:51 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: HOSSEINI, MITRA
FACILITY NUMBER: 073409227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102370(k)
(k) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees, volunteers that require fingerprinting and non-client adults residing in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as one employee's criminal record clearance was not associated to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2026
Plan of Correction
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A criminal record clearance form was provided to the licensee and shall submitted by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sherelle Johnson
NAME OF LICENSING PROGRAM MANAGER:
Liam Bucsko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2026


LIC809 (FAS) - (06/04)
Page: 8 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HOSSEINI, MITRA
FACILITY NUMBER: 073409227
VISIT DATE: 06/12/2026
NARRATIVE
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---Page 2---
Licensee last conducted fire drill 05/12/2026. LPA observed 1 dog in the home.

LPA inspected the backyard. LPA observed age appropriate toys for children to play with. Assembly Bill No. 2866 requires family child care homes with swimming pools to have extra requirements that were not met today; see bottom of the report for details. Facility does not provide transportation for children, but Licensee understands that children cannot be left alone, unattended in parked vehicles. LPA reminded Licensee that when outside of facility, 100% supervision of children in care is required.

Children’s records were reviewed to ensure that each child has an Identification and Emergency form. The licensee Pediatric First Aid and CPR certificate will expire in 07/2027. Required postings were observed near the entrance.

LPA reminded Licensee day care needs to be operated within the limitations and capacity of a Large Family Child Care Home with regards to ratios.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

On or before March 30, 2018, any person who works in a child care facility shall complete Mandated Reporter training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers. Licensee has provided Mandated Reporter certificate and the certificate will expire 06/2028. Licensee's assistant did not possess a Mandated Reporter certificate.

NAME OF LICENSING PROGRAM MANAGER: Sherelle Johnson
NAME OF LICENSING PROGRAM ANALYST: Liam Bucsko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026
LIC809 (FAS) - (06/04)
Page: 9 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HOSSEINI, MITRA
FACILITY NUMBER: 073409227
VISIT DATE: 06/12/2026
NARRATIVE
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---Page 3---
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

In the areas that were evaluated, there were seven (7) violations observed. Seven (7) Type B citations are being issued today. See page 809-D for details.

---Licensee's assistant did not possess criminal record clearance association with the facility.

---Licensee's assistant did not possess documented proof of completed mandated reporter training.

---Licensee's assistant did not possess documentation of the required immunizations or exemptions from immunization.

---Licensee's swimming pool did not possess an approved safety pool cover or an alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water.

---Licensee's swimming pool did not possess a compliant life ring.

---Licensee's swimming pool did not possess a compliant rescue pole.

NAME OF LICENSING PROGRAM MANAGER: Sherelle Johnson
NAME OF LICENSING PROGRAM ANALYST: Liam Bucsko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HOSSEINI, MITRA
FACILITY NUMBER: 073409227
VISIT DATE: 06/12/2026
NARRATIVE
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---Page 4---
---Licensee did not possess a daily inspection log of the facility swimming pool.

Exit interview conducted and report was reviewed with the licensee, Mitra Hosseini. Appeal Rights provided. A Notice of Site Visit form was given and must remain posted for 30 consecutive days.

NAME OF LICENSING PROGRAM MANAGER: Sherelle Johnson
NAME OF LICENSING PROGRAM ANALYST: Liam Bucsko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026
LIC809 (FAS) - (06/04)
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