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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100500
Report Date: 12/08/2021
Date Signed: 12/08/2021 02:49:34 PM

Document Has Been Signed on 12/08/2021 02:49 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:SHARIF MOUSAVI, SARA & KHATAMI, SEYEDEHSARA FCCFACILITY NUMBER:
376100500
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 1DATE:
12/08/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Sara Sharif Mousavi and Seyedehsara KhatamiTIME COMPLETED:
03:00 PM
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On December 8, 2021 at 1:55 p.m. Licensing Program Analyst (LPA) Leilani Curtis conducted an unannounced case management inspection in reference to the licensee’s request to add additional outside play space to the existing licensed play area. Upon arrival LPA met with Licensee Sara Sharif Mousavi and Seyedehsara Khatami and proceeded to tour the facility inside and outside per facility sketch. There was one child in care who is over two years old. The facility was observed operating within ratio and capacity.

On LPA Curtis’s prelicensing report dated 7/1/21 the licensee stated that the children will play in the fenced and gated play area on the right side of the front yard. The licensee is requesting to add the area to the right of the current play area as part of the licensed facility.

LPA toured the front yard and play areas to ensure that the area is safe for the care and supervision of children. There are no poisons, cleaners or other hazardous items observed accessible to children in the front yard play area. The new area is adjacent to the current space and is surrounded by a fence and a connecting gate. The area has a large tree which provides shade. The licensee understands that swings are not to be attached to the tree for the children to use. The licensee states that the children will be supervised at all times when the play area is in use. To access the new area the children will walk through the first play area into the new/second play area. The licensee has submitted an updated facility sketch. Both play areas are approved for use.

The following areas will be used for child care: bedroom #1, bathroom #1, living room/daycare room, bathroom #2 and front yard. The front yard includes two fenced play areas. Off limit areas include: upstairs living room/bedroom #2, kitchen and rear yard.

No deficiencies are cited.

LPA reviewed this report with Licensee and provided a copy of Appeal Rights (LIC 9058 01/16). LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed Licensee post notice of site visit.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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