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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418755
Report Date: 05/29/2024
Date Signed: 05/29/2024 03:59:35 PM

Document Has Been Signed on 05/29/2024 03:59 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:KIUMEHR FAMILY CHILD CAREFACILITY NUMBER:
197418755
ADMINISTRATOR/
DIRECTOR:		KIUMEHR, FLORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 869-9975
CITY:LOS ANGELESSTATE: CAZIP CODE:
90025
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
05/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Flora KiumehrTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 5/29/2024, Licensing Program Analyst (LPA) Judy Laureano, conducted an unannounced Case Management Inspection. LPA Laureano was greeted by Licensee F. Kiumehr who guided LPA on a tour both indoors and outdoors.

LPA met with , Flora Kiumehr and explained the purpose of the visit. During today’s inspections there was 8 children with assistant P. Ravaei, and licensee providing care and supervision.

LPA Laureano reviewed 5 children's file and 2 out of 5 files did not have proof of immunization record, Type B citation issued. LPA reviewed assistant's file and Mandated Reporter Training and proof of immunization record was not available for review, Type B citation issued.

A copy of this report was reviewed and provided to Licensee F. Kiumehr.

Notice of Site Visit and appeal rights were provided.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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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Document Has Been Signed on 05/29/2024 03:59 PM - It Cannot Be Edited


Created By: Judy Laureano On 05/29/2024 at 09:56 AM
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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KIUMEHR FAMILY CHILD CARE
FACILITY NUMBER: 197418755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2024
Section Cited
HSC
1596.8662(b)(1)

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(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.
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Licensee agrees to have assistant P. Ravaei complete the Mandated Reporter Training and submit proof to LPA via email by 6/12/2024
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This requirement is not met as evidenced by assistant P. Ravaei does not have a valid Mandated Reporter Training.
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Type B
05/29/2024
Section Cited
CCR102418(g)

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102418 (g) Immunization
The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
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Licensee agrees to provide a copy current immunization recored for L. Heilbronn and M. Schroeter
Licensee will email LPA by 6/12/2024
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This requirement is not met as evidenced by 2 out of 5 children's file did not have immunization record on file.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claudia Escobedo
LICENSING EVALUATOR NAME:Judy Laureano
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/29/2024 03:59 PM - It Cannot Be Edited


Created By: Judy Laureano On 05/29/2024 at 10:23 AM
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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KIUMEHR FAMILY CHILD CARE
FACILITY NUMBER: 197418755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2024
Section Cited
HSC
1597.622(a)(1)

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(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee agrees to email proof of immunization to LPA by 6/12/2024.
Assistant needs to provide proof of immunization record.
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This requirement is not met as evidenced by assistant's file was incomplete, proof of immunization record was not available for review. (MMR, Dtap and Flu vaccine and/or waiver)
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claudia Escobedo
LICENSING EVALUATOR NAME:Judy Laureano
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
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