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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415968
Report Date: 09/13/2023
Date Signed: 09/13/2023 11:04:03 AM


Document Has Been Signed on 09/13/2023 11:04 AM - 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:8CENSUS: 5DATE:
09/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Shahin Shenas and Nina FathizadehTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Janette Cruz and Jessica Bongardt conducted an unannounced case management during another visit and met with Shahin Shenas and Nina Fathizadeh, Licensees. LPAs also observed two infants, three preschool day care children, and Licensees' adult assistant, Ivonne Vanessa Tovar present in the home during today's inspection. . LPAs reviewed the children's file and provided Licensees with the following forms and regulations for guidance during today's inspection:
LIC9227 Individual Infant Sleeping Plan
Title 22 Infant Safe Sleep

A deficiency was cited, appeal rights were given to Licensee, See (809-D). Exit interview was conducted and reviewed with Shahin Shenas and Nina Fathizadeh, Licensees.

A Notice of Site Visit was given and must be posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
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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Document Has Been Signed on 09/13/2023 11:04 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2023
Section Cited
CCR
102425(j)(2)(D)

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102425 Infant Safe Sleep
(j) The provider shall supervise infants while they are sleeping and adhere to the following requirements:
(2)The provider shall check and document the following:
(D) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:
a. Date.
b. Infant’s name.
c. Time of each 15-minute check.
This requirement was not met as evidenced by:
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Licensees will submit Infant safe sleep checks every 15-minutes. LIcensees will review Infant Safe
Sleep Regulations and submit a statement of understanding regarding infant's file to be maintained regarding supervision.
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Based on observation, Licensees did not comply with the section cited above. Licensees did not maintain documentation of sleep check for C3 and C4 which posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
LIC809 (FAS) - (06/04)
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