198007903-4-2-2025-54-CC-RDEO-DFCQQA-20250402122201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198007903
Report Date: 04/02/2025
Date Signed: 04/02/2025 12:22:26 PM

Document Has Been Signed on 04/02/2025 12:22 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	HOSSEINZADEN FAMILY DAY CARE		FACILITY NUMBER:	198007903
ADMINISTRATOR/ DIRECTOR:	HOSSEINZADEH, KHADIJEH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 597-7212
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 4	CENSUS: 4	DATE:	04/02/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Licensee - Khadijeh Hosseinzadeh		TIME VISIT/ INSPECTION COMPLETED:	12:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) R. Derraco conducted an unannounced annual inspection to the above facility on 04/02/25. LPA arrived at the facility at 09:30AM and met with licensee, Khadijeh Hosseinzadeh, who guided analyst on a tour. LPA did not observe any additional adults in the home. Per Licensee, there are 4 children that are currently enrolled. There were 4 children present upon arrival. This is a two-story home which consists of 6 bedrooms, 6 bathrooms, kitchen, dining room, living room, family room, a detached garage, front yard and backyard (fenced). The off limit areas include 3 bedrooms, 5 bathrooms, living room, detached garage, front yard and backyard. The main care are is located in family room. LPA observed two couches, an area rug, age appropriate toys, a coffee table and a pet cage. Per licensee, she owns 1 pet dog. The pet dog is kept in the off limits back yard during operation hours. Tension gates were observed at two entrances leading from the main care area to the off limits living room. A fireplace was observed in the main care area with a locked fire place cover. The kitchen was observed to have locks on the cabinets beneath the kitchen counter. Sharp and/or pointy objects were observed to be inaccessible in a drawer next to the kitchen sink. A tension gate was observed in a walkway leading from the kitchen to the off-limits living room. Per licensee, she provides food for children in care. Licensee was reminded that children whom bring food from home must have containers individually labelled and properly stored or refrigerated. The bathroom was observed to be clean with an operable sink, faucet and toilet. Bedroom 1 was observed with a crib and a bed. Bedroom 2 was observed with a bed. Bedroom 3 was observed with 2 play pens. Per licensee, each child uses 1 room each for nap, except for bedroom 3. Per licensee, isolation area for children showing signs of illness will be located in the corner of (page 1 of 3)

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Randy Derraco
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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 04/02/2025 12:22 PM - It Cannot Be Edited

Created By: Randy Derraco On 04/02/2025 at 12:01 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HOSSEINZADEN FAMILY DAY CARE	FACILITY NUMBER: 198007903
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2025

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
1 2 3 4	Based on observation, interview and record review, the licensee did not complete mandated reporter training which poses and potential Health, safety and/or personal rights risk to persons in care.
	POC Due Date: 04/16/2025
	Plan of Correction
1 2 3 4	Licensee states she will email LPA a copy mandated reporter AB1207 compliant trainiing certificate by POC date. www.mandatedreporterca.com

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not renew training on pediatric first aid and CPR which poses and potential Health, safety and/or personal rights risk to persons in care.
	POC Due Date: 04/16/2025
	Plan of Correction
1 2 3 4	Licensee states she will email LPA a copy pediatric first aid and CPR training certificate by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Denise Gibbs
NAME OF LICENSING PROGRAM MANAGER:

	Randy Derraco
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HOSSEINZADEN FAMILY DAY CARE	FACILITY NUMBER: 198007903
	VISIT DATE: 04/02/2025

NARRATIVE

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the main care area while they await parent pick up. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted on a cork board located in the off limits living room.

Individuals who reside in the home were noted and discussed. 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.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety,
comfort, and cleanliness. There is telephone service via a cellphone that is used and the cellphone stays at the facility during operation hours. Per Licensee, the home is equipped with central heating and air conditioning. The licensee understands that storage areas for poisons must be locked, not just made inaccessible. The valve on the required 2A 10BC fire extinguisher indicates fully charged, however licensee states she has misplaced the receipt. LPA advised licensee that she must have fire extinguisher serviced annually, or purchase a new fire extinguisher annually. LPA also advised licensee to keep receipt available for review once fire extinguisher is purchased. Smoke and carbon monoxide detectors were tested and are operable. No bodies of water were observed in the back yard play area. Licensee states that there are no firearms stored in the home. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

The licensee has completed training on preventive health practices including Pediatric First Aid and CPR, however it has not been renewed since 09/2024. LPA advised licensee that a citation under California Code of Regulation (CCR) section 102416(c) will be issued. LPA observed that the Licensee does not have proof of the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file. LPA advised licensee that a citation under Health and Safety Code section 1596.8662(b)(1) will be issued. Children’s records were reviewed, including emergency information and were observed to be complete. A current children’s roster was available for review.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep
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NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Randy Derraco
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HOSSEINZADEN FAMILY DAY CARE	FACILITY NUMBER: 198007903
	VISIT DATE: 04/02/2025

NARRATIVE

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webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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 22-02-CCP. 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/.

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.

LPA advised the licensee to access forms, regulations and quarterly updates online at: www.cdss.ca.gov.

The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

Notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with licensee, Khedijah Hosseinzadeh

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NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Randy Derraco
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

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