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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197400845
Report Date: 01/15/2025
Date Signed: 01/15/2025 03:53:57 PM

Document Has Been Signed on 01/15/2025 03:53 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
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/
DIRECTOR:		KHOSHBAKHSH, JACKLINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 840-0738
CITY:LOS ANGELESSTATE: CAZIP CODE:
90036
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 10DATE:
01/15/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Licensee, Jacklin KhoshbakhshTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On January 15, 2025, at 2:20 pm Licensing Program Analysts (LPA) Priscilla Ochoa conducted an unannounced Case Management Inspection – Plan of Correction at the above facility. LPA met with license, Jacklin Khoshbakhsh who guided LPA on a tour of the facility. LPA observed 10 child in care. The purpose of this inspection is to ensure that the facility is in compliance with Title 22 Regulations and the deficiencies cited on 12/26/2024 were corrected.

Licensing staff observed and reviewed the following:

· LIC 9224 has been signed and filed in children files

· Licensee completed First Aid / CPR training

· Licensee is documenting 15 minutes safe sleep log checks for infants 24 months and younger

· Licensee purchased 2A-10BC fire extinguisher

· Licensee and assistant completed mandated reporter training

· Licensee purchased pool alarm, life ring and rescue pole

Letters of Deficiencies Citations Cleared were provided for deficiencies corrected.

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 licensee Jacklin Khoshbakhsh.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Priscilla Ochoa
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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