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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314324
Report Date: 09/09/2025
Date Signed: 09/09/2025 10:56:07 AM

Document Has Been Signed on 09/09/2025 10:56 AM - 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:PARVIZIAN, SHAHRZADFACILITY NUMBER:
304314324
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
09/09/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Licensee Shahrzan ParvizianTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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On 09/09/2025 at 8:35am an unannounced Annual random inspection was conducted at the facility by Licensing Program Analyst (LPA) Anna Chan. LPA met licensee Shahrzad Parvizian and informed the reason for visit. LPA observed licensee caring for 4 infant children at around 9am. Licensee was operating within the licensed capacity as specified on license.

A review of the Facility Personnel Report Summary on this date indicates adult residents who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults including the licensee and 3 minor children living in the home. Facility Day care hours are 6:00am-6:00pm, Monday through Friday. Tuesday is street sweeping day.

All areas on the Facility Sketch LIC999 were inspected, including but not limited to, off-limits areas. The facility is a two-story home with 4 bedrooms, a laundry room, 3 bathrooms, a living room, a playroom, a kitchen, a backyard (fenced), a side yard and a garage. There is a fireplace, located in the living room, barricaded by a mesh screen inside and a 4-panel glass cover and blocked by a piano. Licensee stated that fireplace is not operable. The stairs to the second floor are barricaded by a child proof safety gate. There are safety door knob covers for off-limit areas. Licensee designated the playroom, living room and bathroom downstairs as day care area.

Licensee acknowledges that children are never to enter an off-limit areas of the home.

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Anna Francesca Chan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
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 09/09/2025 10:56 AM - It Cannot Be Edited


Created By: Anna Francesca Chan On 09/09/2025 at 10:19 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PARVIZIAN, SHAHRZAD
FACILITY NUMBER: 304314324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above 4 infant files were incomplete and were missing documents such as; Child 1 (C1), Child 3 (C3) and Child 4 (C4) were LIC700 Identification and Emergency Information, Child 2 (C2), C1, C3, C4 were missing LIC627 Consent for Emergency Medical Treatment, C4 were missing both LIC995A Notification of Parent’s Rights and LIC282 Affidavit Regarding Liability Insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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Licensee stated they will have the parents complete documentation will will provide LPA a copy of the documents by due date od 9/23/25
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Anna Francesca Chan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PARVIZIAN, SHAHRZAD
FACILITY NUMBER: 304314324
VISIT DATE: 09/09/2025
NARRATIVE
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Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections.

The home has age-appropriate toys for the ages served. LPAs verified there is a working telephone service (cellular service), licensee was reminded that childcare phone needs to remain the in the childcare at all times. There are no pools in the facility and none was observed during the visit.

There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshal standards. The facility conducted fire and disaster drill once every 6 months on 06/30/25.

4 Infant records for children present during inspection were reviewed. There’s a 15-minute sleep log for all 4 infants. During record review, 4 infant files were incomplete and were missing documents such as; Child 1 (C1), Child 3 (C3) and Child 4 (C4) were LIC700 Identification and Emergency Information, Child 2 (C2), C1, C3, C4 were missing LIC627 Consent for Emergency Medical Treatment, C4 were missing both LIC995A Notification of Parent’s Rights and LIC282 Affidavit Regarding Liability Insurance. For licensing purposes, infants are children ages 0-24 months. Licensee was reminded NO MORE THAN 3 INFANTS OR 4 INFANTS ONLY. CAP 8 - NO MORE THAN 2 INFANTS, 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.

The licensee’s EMSA approved Pediatric CPR/First Aid certification expires on 01/2026. 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 licensee were reviewed and within compliance, and influenza shot. 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: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Anna Francesca Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PARVIZIAN, SHAHRZAD
FACILITY NUMBER: 304314324
VISIT DATE: 09/09/2025
NARRATIVE
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This facility does not provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. 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: http://www.ada.gov/childqanda.htm

The licensee understands she 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, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

LPAs discussed the safe sleep regulations with licensee 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 as an additional resource. LPAs 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.

Based on interview and record review, the facility was not in compliance and in violation of the California Code of Regulations, Title 22, Division 12 Section 102417(g)(7) Operation of A Child Care Home. See LIC809D for 1 type B violation.

Exit interview conducted and report and deficiency was reviewed with the licensee, Shahrzad Parvizian. A notice of site visit was posted and must remain posted for 30 days. Appeal Rights were provided
End of Report.
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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Anna Francesca Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC809 (FAS) - (06/04)
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