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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198007903
Report Date: 06/28/2022
Date Signed: 06/28/2022 12:46:18 PM

Document Has Been Signed on 06/28/2022 12:46 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:HOSSEINZADEN FAMILY DAY CAREFACILITY NUMBER:
198007903
ADMINISTRATOR:HOSSEINZADEH, KHADIJEHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 597-7212
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
06/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Khadijeh HosseinzadehTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Warren Birks conducted an unannounced Case Management inspection. LPA met with Licensee Khadijeh Hosseinzadeh who guided LPA on a tour of the facility. The purpose of todays inspection is to amend a previous September 14, 2021 report. LPA informed Licensee that report is amended due to a typo of the Licensee's name on page two.

Exit interview was conducted with Licensee Hosseinzadeh. The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Warren Birks
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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