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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404637
Report Date: 03/29/2023
Date Signed: 03/29/2023 04:05:19 PM

Document Has Been Signed on 03/29/2023 04:05 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SHEHABI, FARIDOKHTFACILITY NUMBER:
434404637
ADMINISTRATOR:FARIDOKHT SHEHABIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 260-2561
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
03/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:SHEHABI, FARIDOKHTTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Pete Hernandez and LPM Gladys Kuizon conducted an unannounced Case Management - Other inspection to serve the Immediate Exclusion for staff, Hengameh Sefati. LPA met with licensee, Faridokht Shehabi.

LPA provided the notice of immediate exclusions to Faridokht Shehabi and Hengameh Sefati.

Licensee understands that failure to comply with the California Department of Social Services (CDSS) Order of Exclusion shall be grounds for disciplining her as the licensee, including suspension or revocation of her license.

LPA also provided and reviewed the "Family Child Care Home Addendum to Notification of Parents' Rights Regarding Removal/Exclusion)". Licensee understands that she must provide a copy to the parents and must obtain their original signature and keep the document in the child's file.

Due to the issuance of Type A citation today, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

An exit interview was conducted. A copy of this report and appeals rights were discussed and left with the Licensee, Faridokht Shehabi, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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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