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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197412618
Report Date: 06/05/2024
Date Signed: 06/06/2024 09:01:23 AM

Document Has Been Signed on 06/06/2024 09:01 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/
DIRECTOR:		PAKIZEGEE, AFSANEHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 614-9050
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 0DATE:
06/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Afsaneh PakizegeeTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 06/05/2024 Licensing Program Analyst arrived at above mentioned facility for a case management inspection. LPA was greeted by Licensee, Afsaneh Pakizegee.

LPA toured the facility indoors and outdoors. LPA did not observed any children in care. Licensee's inactive status has expired and LPA wanted to discuss next steps with Licensee. Licensee is requesting to extend the inactive status until 11/5/2024.

LPA discussed the requirements with licensee and provided the LIC 9211.
Licensee is requesting to extend her licensee as inactive as of 6/05/2024 through 11/05/2024. LPA instructed licensee to contact CCL if she is ready to re open before 11/05/2024.

LPA discuss the LIC 311D and LIC 125 with licensee and provided a copy to use as a reference to audit her program. LPA discussed all necessary foms/records to keep in your family child care home.

Copy of report was provided to licensee.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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