<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415968
Report Date: 01/12/2021
Date Signed: 01/12/2021 12:06:32 PM

Document Has Been Signed on 01/12/2021 12:06 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:SHENAS, SHAHIN & FATHIZADEH, NINAFACILITY NUMBER:
434415968
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
01/12/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH: Fathizadeh, NinaTIME COMPLETED:
12:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, Licensing Program Analyst Licensing Program Manager (LPM) Segura, Mary and (LPA) Almaraz, Celi and conducted an announced continuation of pre-licensing visit with applicant Fathizadeh, Nina. Due to COVID-19 and (Department of Public Health guidelines of social distancing, a tele inspection was conducted via Facetime. A request for an e-mail to send completed report and telephone number to a device that is equipped to conduct a Tele-inspection was used.
The purpose of this visit was to discuss the pool in the back yard. There is a pool that is fully fenced within the back yard however, there are four windows behind the fencing that lead directly to the pool. In order to ensure there is no immediate risk to the health and safety of the children in care, the fence should not make a right hand turn, attached to the home. The fence should go in a straight line directly between two wooden fences. The fence itself is least five feet high and is constructed so that the fence does not obscure the pool from view. The fence is made from a hard mesh material. The gate swings away from the pool, self-closes and has a self-latching device, located no more than six inches from the top of the gate. The gap between the fence and the floor is less than one inch. There were three gaps, between fence and pool gate, they are two inches, these have since been closed. There were gaps on both ends of the fence four inches apart. Per LPA request, the fence has been shortened to no more than two inches apart. All measurements were done with a measuring tape. *****1/2
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Araceli Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SHENAS, SHAHIN & FATHIZADEH, NINA
FACILITY NUMBER: 434415968
VISIT DATE: 01/12/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The back area behind the window also must be cleared since fencing will change, it was noted hazardous materials were stacked against house including paint, wooden boards, old tire etc. in the area currently blocked by the pool fencing. Once the fencing changes these would possibly be accessible to children in care. All hazardous items must be removed from area by windows.

LPM conducted an exit interview with the applicant/s and informed applicant/s that a small FCCH license may be approved pending the following: 1. Pool fence must be straight. 2. Hazardous items must be removed from back area or made inaccessible. Once received, a small license for a capacity of 8 will be granted, pending manager approval. This report has been emailed to applicant/s and he/she has agreed to scan a signed copy of report and/or reply by email in lieu of signature. *****2/2
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Araceli Almaraz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2