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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845544
Report Date: 04/04/2024
Date Signed: 10/09/2024 10:16:24 AM

Document Has Been Signed on 10/09/2024 10:16 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
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:GHOLIPOOR FAMILY CHILD CAREFACILITY NUMBER:
334845544
ADMINISTRATOR/
DIRECTOR:		GHOLIPOOR,MEHRNAZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 506-1915
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
04/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Mehrnaz (Mary) Gholipoor-TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On April 04, 2024, at 1:25 PM Licensing Program Analyst’s (LPAs) Anastasia Flores and Gabriela Hernandez, arrived for the purpose of a case management. During several interviews in regard to a complaint investigation dated 1/25/24, it was revealed that an adult#1 is not cleared to be in the facility is a familiar helper with the children in care. Confidential interviews with six out of nine children disclosed that Staff #6 (S6) plays with the children during day care hours. Other confidential interviews with four out of six adults, revealed that S6 is well known and has been observed in the facility with no specified time. Other confidential interviews disclosed that S6 has previously been observed in the facility as an assistant for licensee and that S6 now has a day care with the mother of licensee. Interview with licensee on 2/02/24, denied allegation that S6 is helping in the facility. Interview with licensee stated that S6 has completed the background paperwork and should be cleared by now. Record review in Guardian does not show any documents submitted to CPMB. On December 29, 2023, a letter was mailed to licensee informing that S6 must obtain a California clearance, or a criminal record exemption as required by the department and proof was to be provided by 1/13/24 as of today there are no updated records. Interview with licensee admitted to S6 having been involved with the facility holiday parties and LPA Flores was shown a photo of S6 with the children and parents during a Christmas party in December of 2023.

Based on interviews, and record review this agency has investigated the case management in an appeal process, and the allegation that an uncleared adult has been involved in the facility while children are in care, was unfounded, and the allegation has been dismissed.

A copy of this report, appeal rights, was handed to Licensee Mehrnaz Gholipoor

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Anastasia Flores
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GHOLIPOOR FAMILY CHILD CARE
FACILITY NUMBER: 334845544
VISIT DATE: 04/04/2024
NARRATIVE
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The licensee shall post and provide copies of the report to parents/guardians of the children currently in care at the facility by the next business day and provide copies to the parents/guardians of newly enrolled children at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.
An exit interview was conducted, a copy of this report, 809D, LIC9224, & appeal rights, along with a Notice of Site Visit was handed to licensee, Mehrnaz (Mary) Gholipoor.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Anastasia Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2024 02:03 PM - It Cannot Be Edited


Created By: Anastasia Flores On 04/04/2024 at 01:22 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GHOLIPOOR FAMILY CHILD CARE
FACILITY NUMBER: 334845544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/05/2024
Section Cited
CCR
102370(d)(1)

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102370(d) (1) Criminal Record Clearance; All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This was not met as evidenced by…
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Licensee will not allow Gholnaz Walsh (sister of licensee) in the facility at any time while day care children are present. Licensee will provide LPA Flores a statement via email by 04/05/24.
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Based on interviews and record review, four out of six interviews disclosed that Staff #6 (S6) has been seen as an assistant in the facility within the last three months or sooner on at least one or more occasion. This poses an immediate health, safety, and personal rights risk to children in care.
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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.
SUPERVISOR'S NAME:Pauline Beschorner
LICENSING EVALUATOR NAME:Anastasia Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
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