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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412346
Report Date: 11/30/2022
Date Signed: 11/30/2022 02:29:43 PM

Document Has Been Signed on 11/30/2022 02:29 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:NEYNAVAEI, PERSHENGFACILITY NUMBER:
434412346
ADMINISTRATOR:NEYNAVAEI, PERSHENGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 431-9796
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 5DATE:
11/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Persheng NeynavaeiTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Janette Cruz met with Persheng Neynavaei, Licensee, to conduct an unannounced Plan of Correction (POC) inspection. Purpose of today’s inspection: verify completion of the Plans of Correction resulting from the previous complaint inspection completed on 10/20/22. LPA toured indoor and outdoor areas of the facility. LPA observed four infants and one preschool child with the Licensee and her adult assistant, Fariba Azad, present in the home. LPA observed that the teacher/child ratio was in compliance during today's inspection.

The Facility was issued the Type A Deficiency :
102423 Personal Rights - On 10/07/22, a child (C1) was put on a restraint by being placed in a booster chair with tray, away from other children, while crying for 5 minutes.

LPA notes that plans of correction for Type A deficiency cited on 10/20/22 were submitted to LPA Cruz via email by 10/21/22.

LPA observed signed LIC9224 Acknowledgement of Receipt of Licensing Report in the children's files.

No deficiencies cited during today's inspection. An exit interview was conducted with Persheng Neynavaei, Licensee.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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