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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405382
Report Date: 09/10/2025
Date Signed: 09/10/2025 11:19:01 AM

Document Has Been Signed on 09/10/2025 11:19 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SHAHBAZ, AMENEH TFACILITY NUMBER:
073405382
ADMINISTRATOR/
DIRECTOR:		SHAHBAZ, AMENEH TFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 212-3479
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
09/10/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ameneh T. ShahbazTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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 September 10, 2025, Licensing Program Analyst (LPA) Lorraine Dacanay Breaux conducted an unannounced Required Annual Inspection and met with licensee, Ameneh Shahbaz. LPA was granted entry by licensee and LPA provided LIC126. Present during the inspection was Licensee, fingerprint cleared spouse and four (4) children in care. (Fingerprint cleared assistant arrived during the visit). Hours of operation is Monday - Friday 6:30 AM - 6:00 PM.

The home is a 2 story home, 4 bedrooms and 2.5 bathrooms and rear yard. The home is neat and clean with heating and ventilation for safety and comfort.
ON LIMIT AREAS: Entire first floor, kitchen, living room, family room, playroom and half bathroom.
OFF LIMIT AREAS: Entire second floor, four (4) bedroom (includes the master bed and bathroom, one main bathroom, three (3) car garage and laundry room. ISOLATION AREA: Section in the playroom away from the children in care, until parents arrive.

OUTDOOR PLAY AREA: Rear yard is fully fenced, LPA observed that it is free from defects or dangerous conditions. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection. Licensee confirmed there are no pools and/or bodies of water at the home. Licensee stated there are no firearms/ weapons in the home. Licensee stated she does not provide over night care or transportation at this time. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. The home has a fully charged 2A10BC fire extinguisher located in the kitchen, combo (tested/functioning) working smoke detector/working carbon monoxide detector located in the playroom, first aid kit, and telephone.

809-C (1 of 3)
NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Lorraine Dacanay-Breaux
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2025
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 4
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)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAHBAZ, AMENEH T
FACILITY NUMBER: 073405382
VISIT DATE: 09/10/2025
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
At 10:35 AM, LPA requested and reviewed the files of four (4) children in care and personnel files. All files contained the required Identification & Emergency Information, Parent’s Rights, and Medical Consent forms. The licensee’s Health and Safety training has been completed, and their CPR and First Aid certification is current, expiring 08/2027. LPA observed that the licensee has conducted or documented any fire/disaster drills last one was 06/16/2025. LPA reminded the licensee that disaster drills are required at least once every six months and must be properly documented. The facility roster was reviewed and copy obtained.

LPA reminded licensee that CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility. The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing.

Per licensee does not administer medication at this time.



Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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: http://www.ada.gov/childqanda.htm.

LPA informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The licensee was also reminded that Mandated Reporter Training is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

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.

809-C (2 of 3)

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Lorraine Dacanay-Breaux
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAHBAZ, AMENEH T
FACILITY NUMBER: 073405382
VISIT DATE: 09/10/2025
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
Effective August 1, 2003, California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone and written report with in 7 days.

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-andresources/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.

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.

The licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, Ameneh Shahbaz confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

There are no deficiencies cited today. A notice of site visit was given and must remain posted for 30 days. Appeal rights provided. Exit interview conducted and report was reviewed with the licensee, Ameneh Shahbaz.

END OF REPORT

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Lorraine Dacanay-Breaux
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4