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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404637
Report Date: 04/04/2023
Date Signed: 04/04/2023 12:23:23 PM

Document Has Been Signed on 04/04/2023 12:23 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: 3DATE:
04/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Faridokht ShehabiTIME COMPLETED:
12:35 PM
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Licensing Program Analysts (LPAs) Pete Hernandez and Anna Morales conducted an unannounced Case Management - Other visit to Amend the 9099D page issued on 3/29/2023. LPA met with licensee, Faridokht Shehabi.

The amendment was in the plan of corrections box: "LPM and LPA observed Hengameh Sefati leave the facility."

An exit interview was conducted. A copy of this report was 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: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
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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