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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409477
Report Date: 06/11/2025
Date Signed: 06/11/2025 04:42:02 PM

Document Has Been Signed on 06/11/2025 04:42 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:HEDAYAT-KHOUZANI, ZAHRAFACILITY NUMBER:
073409477
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
06/11/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Hedayat - Khouzani, ZahraTIME VISIT/
INSPECTION COMPLETED:
04:56 PM
NARRATIVE
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On 06/11/25 at 3:10 pm Licensing Program Analysts (LPAs) Mario Caro and Dana Santiago met with Licensee Zahra Hedayat - Khouzani for an Unannounced Case Management Inspection (to determine if the facility is ready for an increase of capacity), explained the purpose of the visit, and was granted entry into the home. LPAs toured the home for a health and safety inspection. Present during the inspection were Licensee, one finger print cleared adult, and 3 infants. The facility’s operating hours are 8:00am to 5:00pm. All required postings are posted on the parent board. This home is a single story house which consist of 3 bedrooms and 3 bathrooms with a detached Accessory Dwelling Unit ADU in the backyard with a separate access pathway from the front left gate of the home. Applicant is reminded that when her children are present in the home during day care hours, they will count in day care ratio requirements. Children will be dropped off at the Main House front door, they will be walking to the ADU through the front yard, past the side gate, down pathway to access the ADU.

The inside and outside of the home were observed to be neat, and clean with age-appropriate materials, furnishings, books, learning materials, and toys for the children. The home has central heating and ventilation for safety and comfort. The vents are located on the ceilings of the home. All toxins, cleaning products, medications, and hazardous materials were observed to be in areas inaccessible to children. There were no baby walkers, or jumpers observed during inspection. LPAs observed a fully charged fire extinguisher 2A-10-BC that meets State Fire Marshal standards and working smoke/carbon monoxide detectors. There is a chicken coop in the backyard of the main house. LPAs reviewed a current Children Roster, and Emergency Disaster Plan LIC610A. Licensee provides snacks and cooks for the children. Food storage areas were observed to be sanitary. Licensee stated there are no firearms in the home.
NAME OF LICENSING PROGRAM MANAGER: Mayla Mendoza
NAME OF LICENSING PROGRAM ANALYST: Mario Caro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HEDAYAT-KHOUZANI, ZAHRA
FACILITY NUMBER: 073409477
VISIT DATE: 06/11/2025
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The main home has a fully charged 2A-10-BC fire extinguishers. The main house and ADU have working dual smoke and carbon monoxide detector and a working telephone. The applicant’s CPR certificate expires on 8/19/25 and the Mandated Reporter Certificate expires on 9/4/25. LPAs observed a sleep sac with encased legs in one of the three infants cribs that Licensee's assistant stated the youngest infant uses. A Type B deficiency will be cited see deficiency page 809-D. As an immediate plan of correction Licensee removed the sleep sac from the facility and stated she will not use that type moving forward. POC cleared by visit.

Main House (Indoor areas)

On Limit Areas: Entrance Hallway, Hallway Bathroom, Living room, Play room adjacent to Kitchen

Off Limit : Kitchen, Dining area, attached Garage, Office/gym room, 3 bedrooms, Master Bathroom, Pantry/Laundry.

Isolation area : Living room

ADU (Indoor areas)

On Limit: Living room, Kitchen, Hallway bathroom

Off Limit : 3 Bedrooms, Master Bathroom

Outdoor Space:

On Limit Areas: Play structure yard in front of ADU, Small yard area behind ADU Living room.

Off Limits Areas: rest of the backyard (fenced off from on limit yard areas), Chicken coop.


Supervision of children was discussed, and Licensee understands that she must be present in the home during 80% of the operating hours and ensure children are always supervised.

Licensee was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
NAME OF LICENSING PROGRAM MANAGER: Mayla Mendoza
NAME OF LICENSING PROGRAM ANALYST: Mario Caro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HEDAYAT-KHOUZANI, ZAHRA
FACILITY NUMBER: 073409477
VISIT DATE: 06/11/2025
NARRATIVE
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On 06/11/25 the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

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



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.

LPA discussed the Safe Sleep regulations with Licensee and 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. LPAs 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.

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/.
NAME OF LICENSING PROGRAM MANAGER: Mayla Mendoza
NAME OF LICENSING PROGRAM ANALYST: Mario Caro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HEDAYAT-KHOUZANI, ZAHRA
FACILITY NUMBER: 073409477
VISIT DATE: 06/11/2025
NARRATIVE
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.
continued on 809-C

In the areas that were evaluated, one Type B regulatory violation was cited.



On 05/30/25 a fire clearance was granted to this facility by the Oakland fire department. All documents have been received for the increase of capacity application. The licensee was reminded that an assistant is needed with a large family child care home license, and whenever an assistant is not present, the licensee will comply with the capacity requirements for a small child care facility home.

As of todays date 06/11/25 this facility is approved to operate as a large family child care home.

Exit interview conducted and report was reviewed with the Licensee. During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility.



A Notice of Site Visit was given to Licensee, Zahra Hedayat - Khouzani and must remain posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Mayla Mendoza
NAME OF LICENSING PROGRAM ANALYST: Mario Caro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2025 04:42 PM - It Cannot Be Edited


Created By: Mario Caro On 06/11/2025 at 04:17 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HEDAYAT-KHOUZANI, ZAHRA
FACILITY NUMBER: 073409477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2025
Section Cited
CCR
102425(f)

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102425(f) Infant Safe Sleep (f) An infant shall not be swaddled while in care.
This requirement is not met as evidenced by:
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Licensee immediately removed the sleep sac from the facility, and stated they will refraim from using them moving forward. POC Cleared by visit.
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Based on observation, the licensee did not comply with the section cited above that LPAs observed a sleep sac in one of the three infants crib which licensee's assistant stated the smallest infant uses this poses 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.
Mayla Mendoza
NAME OF LICENSING PROGRAM MANAGER:
Mario Caro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
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