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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197400845
Report Date: 01/17/2024
Date Signed: 01/17/2024 10:28:03 AM

Document Has Been Signed on 01/17/2024 10:28 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:KHOSHBAKHSH, JACKLIN F.D.C.FACILITY NUMBER:
197400845
ADMINISTRATOR:KHOSHBAKHSH, JACKLINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 840-0738
CITY:LOS ANGELESSTATE: CAZIP CODE:
90036
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: DATE:
01/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jacklin KhoshbakhshTIME COMPLETED:
09:46 AM
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On January 17, 2024, at 09:56AM Licensing Program Analysts (LPAs) Shushanik Safaryan and Monique Ayala conducted an unannounced Case Management Inspection – Plan of Correction at the above facility. A COVID-19 risk assessment was conducted prior to entering the facility. LPAs met with licensee , Jacklin Khoshbakhsh .LPAs observed 7 children in care with licensee and assistant ,at 9:30 AM. The purpose of this inspection is to ensure that the facility is in compliance with Title 22 Regulations and the deficiencies cited on 12/21/2023 were corrected.

Licensing staff observed and reviewed the following:

· The licensee added additional iron gate to the side of the pool to block access to the side door of the pool . Lpa`s observed lock on the side gate with the key . Per licensee, the gate will be locked all the time .LPA`s took measurements of the iron gate . Pictures were taken that met height and length requirements .

· Licensee added child safety gate to the kitchen door to block children’s access to the kitchen .

· Licensee added safety latch to the refrigerator and freezer outside for the children’s safety while they are playing outside .

· Licensing staff observed signed LIC 9224 in children’s file and deficiency page and report posted on the children's file .

· Licensing staff observed cover on the open floor heater .

LPA`s observed Sleeping log in infants records .

· Letters of Deficiencies Citations Cleared were provided for deficiencies corrected.

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KHOSHBAKHSH, JACKLIN F.D.C.
FACILITY NUMBER: 197400845
VISIT DATE: 01/17/2024
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The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00

An exit interview was conducted, and a copy of this report was provided to Jacklin Khoshbakhsh along with Appeal Rights.

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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