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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418638
Report Date: 08/31/2022
Date Signed: 08/31/2022 11:17:37 AM

Document Has Been Signed on 08/31/2022 11:17 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:MIRZADEH FAMILY CHILD CAREFACILITY NUMBER:
197418638
ADMINISTRATOR:MIRZADEH, MANIJEHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 606-8634
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
08/31/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Manjeh Mirzadeh Licensee and Licensee's assistant TIME COMPLETED:
11:25 AM
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On 08/31/2022 9:10am Licensing Program Analyst (LPA) Denise Miranda conducted an unannounced continuation Annual Required Inspection and was met by Licensee, Manijeh Mirzadeh. Also present was one Licensee’s Assistant 3, and 6 children (who 4 were infants). Per Licensee, her operation hours is from 7am to 6pm – Monday – Friday.
A copy of LIC126 Entrance of checklist was provided today and on the previous visit on 08/26/2022.
Per Sketch, Licensee, converted the detached recreation room along with a bathroom. Licensee provided copy of certificate of occupancy and showing that detached converted an existing 1 story has a new address 6451 N. Bothwell Road, 91335.
LPA observed a fence, separating the detached converted recreation room to the backyard. Licensee, will submit an update LIC999A. Licensee was advised that any changes she shall to report to El Segundo Regional office.
The following areas are designated as follows and Licensee confirmed that the: Living room, play room, bedroom #1 and Bathroom#2 , backyard were accessible to the children in care.
The off-limit: the recreation room (converted garage), carpool, kitchen, laundry room, bedroom#2#3#4, and bathroom #1.
Licensee provide proof of Mandated Reporter Training for her, that it was completed on 08/26/2022 and is due renewal on 08/26/2023, and Licensee’s took the class of pediatric CPR/First Aid completed on 08/28/2022, Licensee will submit a copy of the CPR card no later than 09/2/2022.

LPA observed the bedroom#1, that children using for napping. LPA observed, that licensee, in compliance with play pens and crib and with the safe sleep regulaiton. Licensee understand the regulation of safe sleep, that LPA provided consultation on previously visit on 8/26/2022 and today.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MIRZADEH FAMILY CHILD CARE
FACILITY NUMBER: 197418638
VISIT DATE: 08/31/2022
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On 08/27/2022 LPA provided a brochure of Safe Sleep (SIDS), sample of safe sleep log,
questions and answers about safe sleep, a copy of lic9227 Individual Infant Sleeping Plan , form and a copy of lic311D Forms/Records Keep In Your Family Child Care Home. Also, LPA provided consultation.

Staff interview conducted and documented at 9:37am.

During this inspection, LPA provided a copy of regulation - Staffing Ratio and Capacity, 102426. Licensee, understand that she can not have more than 4 infants per time.

The deficiencies that was cited on 08/26/2022m Licensee will provide the corrections on 9/2/2022.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, today, no deficiencies are cited.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee. Report, Appeal Rights and Notice of Site Visit were given to Licensee.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC809 (FAS) - (06/04)
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