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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314063
Report Date: 07/17/2025
Date Signed: 07/17/2025 04:01:14 PM

Document Has Been Signed on 07/17/2025 04:01 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SHIRI, KHATEREHFACILITY NUMBER:
304314063
ADMINISTRATOR/
DIRECTOR:		SHIRI, KHATEREHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 473-0777
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
07/17/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek. LPA met with licensee, Khatereh Shiri and her assistant, Mohsen Doucheghani. LPA observed the 7 children of whom three were under 24 months old. (11 months old, and two 17 months old). Licensee was operating within the licensed capacity as specified on license for Large Family Childcare Home.

A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

According to licensee, currently there are two adults including the licensee, and three minors living in the house. Day care hours of operation is Monday through Friday from 7:00 am-5:30 pm.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of baby gates. The childcare area consists of family room, one bedroom, children's bathroom and backyard. . There is one gate installed at the kitchen side and the children's area to make the kitchen inaccessible to children. There is a baby gate installed between the children's area and hallway entrance to make the hallway entrance inaccessible to children. There is a gate installed in front of the stairs to make upstairs inaccessible to children. Garage is equipped with two locks and is inaccessible to children. Back yard is for children's use. There is a small slide and swings in the backyard. The flooring is cushioned with artificial grass.
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NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SHIRI, KHATEREH
FACILITY NUMBER: 304314063
VISIT DATE: 07/17/2025
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There are age appropriate toys and equipment for children to play outside. There are 3 cribs available for infants. Older children nap on cots. LPA observed a rocking crib that did not meet the licensing requirements. This equipment was returned to the owner.

There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards.

Detergents, cleaning compounds, medicines, and other items which could pose a danger to children were not readily available to children they were stored inaccessible to children, none were observed during inspection.

According to licensee, there is no firearm in the facility. There is one cat living in the home kept upstairs. LPA verified there is a working telephone service (cellular service).

The licensee does have a current roster of children in care. Fire Drill was available. The last fire drill was conducted 4/13/2025. Children’s records for children present during LPA’s inspection were reviewed. Seven files were reviewed. The log for every 15 minutes check on napping children under 24 months old were available. LIC 9227 (Individual Infant Sleeping Plan) for infants under 12 months old were available on their files. The licensee and her assistant's CPR/First Aid certifications are current. They expire 4/20/2026.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for the licensee and her assistant were within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.
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NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SHIRI, KHATEREH
FACILITY NUMBER: 304314063
VISIT DATE: 07/17/2025
NARRATIVE
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Mandated Reporter Training Certificate for the licensee expires 4/18/2026.

Incidental Medical Services (IMS) policy was discussed. For 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/.

The licensee understands they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization, Pediatric CPR/First Aid, and mandated reporter training.

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance before working 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.

LPA discussed the safe sleep regulations with Licensee Khatereh Shiri and discussed the Child Care Licensing Safe Sleep webpage at:

https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep,

LPA also informed Licensee, Khatereh Shiri of the importance of checking for recalled as infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and

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NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SHIRI, KHATEREH
FACILITY NUMBER: 304314063
VISIT DATE: 07/17/2025
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recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee, Khatereh Shiri was informed of the MyChildCarePlan.org site, 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. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-care- licensing/subscribe and select the Child Care option to receive email communication. (The licensee is already signed up for this purpose).

In the areas that were evaluated, the following deficiencies were observed of the California Code of Regulations, Title 22, Division 12 on this inspection. Please see LIC 809D for details of deficiencies.

A notice of site visit was given to licensee, Saeedeh Rad and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to post will result in Civil Penalties of $100.00.

Exit interview conducted and report was reviewed with the licensee, Khatereh Shiri in her native language.

End of report

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2025 04:01 PM - It Cannot Be Edited


Created By: Mahnaz Malek On 07/17/2025 at 03:11 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SHIRI, KHATEREH
FACILITY NUMBER: 304314063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)(1)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (1) All cribs or play yards shall meet the United States Consumer Product Safety Commission safety standards.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one count out of 7 counts that there was a rocking crib for C # 7 not meeting the above requirements which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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The licensee stated there are cribs that meets the above requirements but one was offered by a parent. During inspection, the equipment was put away to return to parent.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record, the licensee did not comply with the section cited above in 3 counts out of 7 files that C1, C5, and C7 missing the above forms which poses a potential health, and safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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The licensee agreed to send the verification of completion of this form and scan them to LPA's email address by the due date of 7/23/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Thuy Ho
NAME OF LICENSING PROGRAM MANAGER:
Mahnaz Malek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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