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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195700534
Report Date: 05/13/2025
Date Signed: 05/13/2025 11:27:52 AM

Document Has Been Signed on 05/13/2025 11:27 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:NIK FAMILY CHILD CAREFACILITY NUMBER:
195700534
ADMINISTRATOR/
DIRECTOR:		FATEMEH NIKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 456-2981
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/13/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Fatemeh NikTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an announced pre-licensing inspection for a large family child care at the above facility on 05/13/2025 at 8:30 AM. This is a change of location, previous license number 197493662. LPA met with Applicant Fatemeh Nik, who guided LPA on a tour of the facility. Also present was Applicants’ brother and adult son. Other adults residing in the home is the Applicant’s adult son. There were no children present when LPA arrived. Per Applicant, hours of operation will be Monday through Friday, 6:30am to 5:00pm. Applicant states they will provide care for children 0 weeks to 13 years of age.

This is a two-story home with an open floor plan consisting of four bedrooms, two bathrooms, living room, dining room, kitchen, attached ADU (with a different address), front yard and back yard. The home was inspected for safety, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Areas used by children include: Bedroom #1, bathroom #1, bathroom is connected to bedroom #1 and is next to the living room, dining room and backyard. Applicants wants to use her bedroom as the primary place for the day-care. LPA informed applicant since their is a bed in the middle in of the room there is not enough space for the children in the room, applicant wants to use the areas around the bed for the children. Areas off limits include: The second floor which includes three bedrooms and one bathroom. On the first floor the living room, ADU and kitchen is off limits. LPA informed Applicant there needs to be a gate at the bottom of the stairs. Knives and other sharp utensils are stored on the top shelf in the kitchen cabinet. Cleaning
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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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 7
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NIK FAMILY CHILD CARE
FACILITY NUMBER: 195700534
VISIT DATE: 05/13/2025
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products are located on the top shelf in the kitchen cabinet inaccessible to children.

Applicant wants to run day-care only out of the attached garage that was converted to an ADU with a separate address. LPA informed Applicant the day-care can not be conducted out of the ADU as it is not the address listed on the application, LPA informed Applicant if they day-care wants to be ran out of the ADU she must submit a new application and live in the ADU. Per Title 22 regulation for a family child care home, day-care must be operated in the applicants primary residence. LPA informed applicant, the ADU cannot be used at all for the day-care as it will not be apart of the license.

The home is clean and orderly, there are no outlet covers throughout the home. LPA informed applicant, outlet covers must be installed on the first floor in the day-care areas. Combination smoke/carbon monoxide detector was observed, tested and found to be operable.

Applicant has completed the required health and safety training, the Pediatric First Aid and CPR. Applicant has proof of immunization against pertussis and measles, and declination letters for influenza on file. Proof of Mandated Reporter Training was also provided.

Applicant states they will provide food for the children. LPA reminded Applicant that food brought from home should be labeled with the child's name and properly refrigerated. LPA observed age-appropriate toys and learning materials. The required (2A10BC) fire extinguisher was observed in the bathroom and was purchased in February 2025. Per Applicant, there are no weapons or firearms in the facility.

Per Applicant, the children will use the backyard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that could be hazardous to children in care. There are no pools or spas, or other bodies of water.

The isolation area for a sick children waiting to be picked up will be in the dining area, away from other children.



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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NIK FAMILY CHILD CARE
FACILITY NUMBER: 195700534
VISIT DATE: 05/13/2025
NARRATIVE
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The Applicant provided proof of control of property. Applicant owns the property.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 informed Applicant any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Fire and safety drills must be performed every six months and documented for review by the Department and smoking tobacco is not allowed in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present.

A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated.

The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, batteries should be replaced.

Changes should be reported the to the Department as soon as they occur such as construction and remodeling.

Telephone number changes and/or if you move from home.

LPA reviewed and provided copies to the applicant regarding LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Page 3.
NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NIK FAMILY CHILD CARE
FACILITY NUMBER: 195700534
VISIT DATE: 05/13/2025
NARRATIVE
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CHILDREN'S RECORDS REQUIREMENTS:
• LIC 700 Identification and Emergency Information
• LIC 627 Consent for Emergency Medical Treatment
• LIC 282 Affidavit Regarding Liability Insurance
• LIC 9150 Parent Notification Additional Children in Care
• LIC 9927 Individual Infant Sleeping Plan
• LIC 995A Notification of Parent’s Rights
• Immunization Record
• 15 minute safe sleep log

FACILITY RECORDS:
• LIC 624B Unusual Incident/Injury Report
• LIC 9040 Child Care Facility Roster
• LIC 9052 Employee Rights,
• LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
• LIC 9149 Property Owner/Landlord Consent Form
• LIC 9151 Property Owner/Landlord Notification Form
• Proof of current pediatric CPR and First Aid Certificates
• Copy of your deed or lease/rental agreement
• Documentation of Fire and Disaster drills
• Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza
• Mandated Reporter certificate – www.mandatedreporterca.com– must be renewed every two (2) years

FORMS TO BE POSTED
• LIC203 Facility License
• LIC 610A Emergency Disaster Plan
• LIC 9148 Earthquake Preparedness Checklist
• PUB394 Notification of Parents Rights Poster


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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NIK FAMILY CHILD CARE
FACILITY NUMBER: 195700534
VISIT DATE: 05/13/2025
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 To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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) or (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.

Applicant 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.



LPA discussed the safe sleep regulations with applicant 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 https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources /safe-sleep as an additional resource. LPA also informed applicant 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.

On this date, 03/27/25, 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.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NIK FAMILY CHILD CARE
FACILITY NUMBER: 195700534
VISIT DATE: 05/13/2025
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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.

Applicants application will be submitted for approval for a large family child care with a capacity of 14 once LPA receives proof of the following:
  • Outlet covers in the day-care areas.



Page 6.
NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
Page: 7 of 7