434416923-9-16-2026-07-CC-JBER-DXYUM7-20260916154152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416923
Report Date: 09/16/2026
Date Signed: 09/16/2026 03:42:30 PM

Document Has Been Signed on 09/16/2026 03:42 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	JAFARNEJAD, KAVEH		FACILITY NUMBER:	434416923
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 8	DATE:	09/16/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Kaveh Jafarnejad - Licensee		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 09/16/2026, Licensing Program Analysts (LPAs), Jennifer “Jen” Beehler and Tra Dinh conducted an unannounced Annual/Random Inspection. Upon arrival, LPAs were granted access by the Facility Representative. LPAs provided the reason for the visit, conducted a tour and collected the census. There were eight (8) children (2-infants/6-preschool age) and three (3) staff (Licensee and 2-helpers) present which is compliant with ratio and capacity requirements. LPAs observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday, 08:30AM-05:30PM. There are no active waivers. Licensee states that he is the only adult that lives in the residence. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. All adults present have criminal record clearance and are associated on the Guardian Roster for the facility. Continued on Page 2

Adam Hamer
Jennifer Beehler
	DATE: 09/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 09/16/2026 03:42 PM - It Cannot Be Edited

Created By: Jennifer Beehler On 09/16/2026 at 02:14 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JAFARNEJAD, KAVEH	FACILITY NUMBER: 434416923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as no emergency drills have been conducted at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2026
	Plan of Correction
1 2 3 4	Licensee to conduct an emergency drill and log the drill. Licensee to provide LPA with a plan on how he will maintain compliance throughout the year by POC due date.

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 0 out of 3 staff did not have flu vaccinations/declinations. Staff were missing avnegative TB test that was completed within one year of employment or sooner. These deficiencies pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2026
	Plan of Correction
1 2 3 4	Licensee to provide proof, by POC due date, of complete staff files along with a checklist for staff files to ensure compliance is maintained.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Adam Hamer
NAME OF LICENSING PROGRAM MANAGER:

	Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/16/2026 03:42 PM - It Cannot Be Edited

Created By: Jennifer Beehler On 09/16/2026 at 02:20 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JAFARNEJAD, KAVEH	FACILITY NUMBER: 434416923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.9595(c)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Four (4) out of five (5) children's files reviewed did not have an LIC9224 Receipt acknowledging the Type A citiation that was issued to the facility on 09/25/2025.This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2026
	Plan of Correction
1 2 3 4	Licensee to provide a copy of the report dated 09/25/2025 which documents a Type A citation to all parents of children currently enrolled and newly enrolled until 09/25/2026. Licensee to provide the Department with proof by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Adam Hamer
NAME OF LICENSING PROGRAM MANAGER:

	Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JAFARNEJAD, KAVEH	FACILITY NUMBER: 434416923
	VISIT DATE: 09/16/2026

NARRATIVE

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LPAs reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The provider has not conducted a fire drill in the past year. LPAs reminded the Licensee of the requirement to complete a fire/disaster drill every six months. LPAs observed a fully charged 4A60BC fire extinguisher last serviced 08/31/2026 which is compliant with State Fire Marshall Regulations. LPA observed a fully functioning smoke detector and carbon monoxide detector. Licensee states that he does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Indoor areas of the home were inspected by the LPAs today and observed to be clean, orderly, and safe for the day care children. Off-limits areas of the home (indoors): 1 bedroom and the garage. There are no open-faced heaters in the home. The fireplace is boarded up with book shelves in front of it, inaccessible from children in care. LPAs observed sufficient age-appropriate materials, toys, and play equipment in the home. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. Drinking water is readily available for children in the facility via water dispensers with children bringing a water bottle from home labeled with the their names. The bathroom used for the day-care is clean, sanitary, and operable. The Licensee has a working telephone in the facility. This is a single story home and no stairs are present.

The backyard area and front yard area of the home was inspected. LPA observed sufficient play equipment and supplies for the children that are in good condition and age-appropriate. Off-limit areas outside of home include: both side yard. No outdoor bodies of water were observed during todays inspection.

Continued on Page 3

NAME OF LICENSING PROGRAM MANAGER: Adam Hamer
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JAFARNEJAD, KAVEH	FACILITY NUMBER: 434416923
	VISIT DATE: 09/16/2026

NARRATIVE

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Infant Safe Sleep regulations (PIN 20-24-CCP) were discussed with the Licensee, including the Individual Infant Sleeping Plan (LIC9227). LPA reminded Licensee that infants up to 12 months of age should be placed on their back to sleep, that cribs should be free of all loose articles and hanging objects, and that infants should not be swaddled. Infants should be supervised while sleeping and documentation of sleep checks every 15 minutes should remain in the infant’s file. Documentation should include the time of the check, the infant’s physical condition, and initials of the staff member checking on the infant.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Five (5) children’s files were reviewed during todays inspection for the following documents:
Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Acknowledgment of Receipt of Licensing Report (LIC9224) dated 09/25/2025, Immunization Records (PM286), Individual Infant Sleep Plan (LIC9227) and sleep check documentation. LPAs observed some files to be missing documentation.

Three (3) staff files were reviewed for the following records: Employee Rights (LIC9052), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). There is at least one staff member present with current CPR/First-Aid that expires 08/17/2027. The Licensee has current Mandated Reporter Training that expires on 03/25/2027. LPA reminded the Licensee that training must be renewed by all staff every 2 years. Some staff files were incomplete.

Continued on Page 4

NAME OF LICENSING PROGRAM MANAGER: Adam Hamer
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JAFARNEJAD, KAVEH	FACILITY NUMBER: 434416923
	VISIT DATE: 09/16/2026

NARRATIVE

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Supervision of children was discussed with the Licensee and he understands that he must be home during day care hours and ensure that children are supervised at all times. The Licensee states that he does not transport any day care children. LPAs reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

On 08/18/2026, the Department received an application requesting a Large Family Child Home (FCCH) license which would increase the capacity to 14 children. A fire clearance was granted on 08/31/2026 for all on limits areas of the day care.

Licensee was informed that the following conditions must be met prior to granting a Large FCCH:
All deficiencies cleared in accordance with Health and Safety Code along with Title 22 written directives.

As a result of todays inspection, three (3) Type B Deficiencies are cited along with one Technical Violation. More details provided on the attached supporting documents. Exit interview conducted with the Licensee. Report was reviewed and provided to the Licensee, Kaveh Jafarnejad, along with appeal rights.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

NAME OF LICENSING PROGRAM MANAGER: Adam Hamer
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026

LIC809 (FAS) - (06/04)

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