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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313969
Report Date: 01/14/2022
Date Signed: 01/14/2022 02:20:00 PM

Document Has Been Signed on 01/14/2022 02:20 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:EJTEHADI, ZAHRAFACILITY NUMBER:
304313969
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
01/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Applicant Ms. Ejtehadi, Zahra TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Desai, Ketki conducted a follow up Pre-Licensing inspection (POC) to ensure the listed corrections met the requirements.
LPA met with Applicant Ms. Ejtehadi, Zahra who gave the tour of the home.

The following corrections were made by the applicant.
1) Installation of a child safety gate at the entrance of the family room. (completed)
2)Installation of child safety gate on the side of the dining area (completed)
3)Install a safety barrier on the open fire place in the living area. (Applicant has installed a canvas board in the open space, covering the fire place)
4) Install a safety barrier on the other end of the kitchen. (completed)
5)Install child locks on the three cabinets on the second level of the home, in front of the stairway. (applicant has installed safety locks on this cabinets)
6) 6) Parent board. (Applicant has installed the parent board at the entrance of the Day care room on the second level the designated Day care room.)

The facility now is in compliance with Title 22 regulations for Small Family Child care home. License shall be issued upon receiving the final approval from the Management.

Appeal rights were presented and Exit interview was conducted with applicant Ms. Ejtehadi, Zahra
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022
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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