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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415205
Report Date: 12/21/2023
Date Signed: 12/21/2023 01:27:18 PM

Document Has Been Signed on 12/21/2023 01:27 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:SHAGHASI, FARIHAFACILITY NUMBER:
434415205
ADMINISTRATOR:SHAGHASI, FARIHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 289-8519
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 6DATE:
12/21/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Narjessadat SeyedinTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Mel Matos conducted a Required - 3 year inspection at the day care today. LPA met with Narjessadat Seyedin, adult assistant, and explained the nature of today's inspection. LPA also observed one additional adult assistant (Zahra Firozi) and six day care children (2 infants & 4 preschool) in the home during today's inspection. Narjessadat presented identification to LPA verify her identity and the identity of Zahra Firozi, second adult assistant.

Narjessadat states that Fariha Shaghasi, Licensee, is currently unavailable and thus not present in the home. Narjessadat contacted Licensee via telephone and LPA explained the nature of today's inspection to Fariha. Licensee states that she is at a doctor's appointment and thus unavailable at this moment.

LPA provided Narjessadat with the Entrance Checklist - Family Child Care Homes (LIC 126) during today's inspection. LPA observed valid CPR/First Aid certifications for Narjessadat (expiration: 10/17/2025) and Zahra Firozi (expiration: 09/24/2024) in the home during today's inspection.

Narjessadat states that the day care will be closed from December 25, 2023 to January 1, 2024 for the Christmas/New Year break. LPA advised Narjessadat that a follow up inspection will be conducted after January 1, 2024.

Exit interview conducted and report was reviewed with the adult assistant, Narjessadat Seyedin. No deficiencies issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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