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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100360
Report Date: 09/03/2021
Date Signed: 09/03/2021 08:45:58 AM

Document Has Been Signed on 09/03/2021 08:45 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:DIZAYI, ROZHAN FAMILY CHILD CAREFACILITY NUMBER:
376100360
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/03/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rozhan DizayiTIME COMPLETED:
09:00 AM
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On 9/3/21 @ 8:30AM, LPA Nancy Diaz conducted an unannounced inspection for the purpose of observing the correction to deficiency cited on 8/20/2021.

Mrs. Dizayi installed a 5 ft. iron fence that is not climbable. However, the gate is not self-latching. Mrs. Dizayi stated that she will have her installer come and install a self-latching gate.

An exit interview was conducted with Mrs. Dizayi. LPA provided Mrs. Dizayi a copy of this report with appeal rights. Notice of site visit was provided and must post for 30 days.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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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