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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197412618
Report Date: 04/10/2023
Date Signed: 04/10/2023 10:55:21 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/10/2023 10:55 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:PAKIZEGEE FAMILY CHILD CAREFACILITY NUMBER:
197412618
ADMINISTRATOR:PAKIZEGEE, AFSANEHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 614-9050
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 0DATE:
04/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Afsaneh PakizegeeTIME COMPLETED:
10:00 AM
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On 4/10/2023 Licensing Program Analyst arrived at 11733 Tennessee Avenue, Los Angeles, CA 90025 and was greeted by Licensee, Afsaneh Pakizegee.

LPA toured the facility indoors and outdoors. LPA did not observed any children in care. LPA is attempting to complete an annual inspection but licensee stated she has not had any children enrolled since 4/2022.

Licensee stated the need to request an inactive status. LPA discussed the requirements with licensee and provided the LIC 9211.
Licensee is requesting to place her licensee as inactive as of 4/10/2023 through 4/9/2024. LPA instructed licensee to contact CCL if she is ready to re open before 4/9/2024.

LPA discuss the LIC 311D and LIC 125 with licensee and provided a copy to use as a reference to audit her program.

LPA provided licensee a copy of this report.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
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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