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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376301165
Report Date: 09/12/2025
Date Signed: 09/12/2025 04:28:13 PM

Document Has Been Signed on 09/12/2025 04:28 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:GHIYASI FAMILY CHILD CAREFACILITY NUMBER:
376301165
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
09/12/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Mahboubeh GhiyasiTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) William Chancellor conducted an unannounced annual inspection for Ghiyasi Family Childcare (FCCH) on September 12, 2025, at 2:20 PM. LPA met with Licensee (LIC) Mahboubeh Ghiyasi and daughter Kiyana Pahlevani who granted entry and provided LPA with a tour through the FCCH.

The facility operates Monday through Saturday, 6AM to 6PM, serving children birth to 12 years old. Children primarily utilize the entry living room, enclosed patio, and bedroom 1 on the first floor. Off-limit areas include: entire second floor, garage, and laundry room. The Off-limit areas utilize child safety locks and lockable doorknobs, making these areas inaccessible to children. The facility is licensed as a small FCCH with a maximum capacity of eight (8) children. Present during the inspection were five (5) daycare children, licensee and one assistant. Four of the five children were infants, therefore ratios were exceeded during today's inspection. Children were observed to be transitioning from nap, engaging with their peers with age-appropriate toys and listening to various music and videos.

A working cell phone is available, and the current phone number on file is correct. A fully charged fire extinguisher (2A:10BC) was observed to be mounted by the entry door. LPA observed operational dual smoke and carbon monoxide detectors mounted throughout the home. LPA reminded licensee that all poisons and cleaning compounds deemed hazardous must be locked by a key. The license stated they understand that all off-limit areas are made inaccessible by child safety gates, doorknobs or lock and key, and must be operational during daycare hours.

A current roster was available for review during inspection. LPA confirmed the required postings, including the Facility Sketch, Emergency Disaster Plan, License and Notification of Parent’s Rights, are displayed in the daycare parent board. Fire and disaster drill documentation was available, documented in August 2025. Licensee was reminded that drills are required at least every six months, documenting fire and earthquake drills on different dates.

NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: William M Chancellor Jr.
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
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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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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Document Has Been Signed on 09/12/2025 04:28 PM - It Cannot Be Edited


Created By: William M Chancellor Jr. On 09/12/2025 at 03:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GHIYASI FAMILY CHILD CARE
FACILITY NUMBER: 376301165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation. interview and record review, the licensee did not comply with the section cited above in two of three infants observed. Where C1 was utilizing a sleep sack without a medical exception on file. C1 and C3 had blankets inside their bassinet when napping. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Licensee will email a written understanding of Title 22 102425 Infant Safe Sleep. C1 must obtain a medical exception to allow for the use of a sleep sack. CCL considers sleep sacks to be considered a swaddeling device.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in three of three infants enrolled. Where C1-C3 did not have a LIC 9227 available on file. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Licensee will email LPA an LIC 9227 for C1-C3.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Pauline Beschorner
NAME OF LICENSING PROGRAM MANAGER:
William M Chancellor Jr.
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2025 04:28 PM - It Cannot Be Edited


Created By: William M Chancellor Jr. On 09/12/2025 at 03:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GHIYASI FAMILY CHILD CARE
FACILITY NUMBER: 376301165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.5(b)(1)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (1) Four infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above where five children were present, four of whom were infant. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Licensee will email LPA a written understanding of Title 22 102416.5 Staffing and Ratio. Additionally, licensee will provide confirmation that days of enrollment for part time children.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Pauline Beschorner
NAME OF LICENSING PROGRAM MANAGER:
William M Chancellor Jr.
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GHIYASI FAMILY CHILD CARE
FACILITY NUMBER: 376301165
VISIT DATE: 09/12/2025
NARRATIVE
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Licensee stated there are no firearms present in the FCCH at this time. Licensee stated they understand that all firearms, weapons, and ammunition must be locked separately and made inaccessible as per Title 22 Regulations.

LPA confirmed there are no pools or other bodies of water present at the FCCH property at this time. Licensee stated they understand that all bodies of water including ponds, above ground pools, spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar products must be emptied immediately after use and stored in an upright position.

Both children and employee records were audited during this inspection. Mandated Reporter Training is on file and current for licensee, expiring in October 2026. The License was reminded that Mandated Reporter must be renewed every two years. Licensee Pediatric CPR and First Aid certification is current, expiring in June 2026.

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 995A Notification of Parent’s Rights

• Immunization Record

• CDPH 286

• LIC 9227 Individual Sleep Plan- required for infants 12 months or younger

• 15 min sleep logs for infants 0-24 months. Including position, when under 12 months.

NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: William M Chancellor Jr.
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GHIYASI FAMILY CHILD CARE
FACILITY NUMBER: 376301165
VISIT DATE: 09/12/2025
NARRATIVE
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FACILITY RECORDS:

• LIC 624B Unusual Incident/Injury Report

• LIC 9040 Child Care Facility Roster

• Copy of your deed or lease/rental agreement

• Documentation of Fire and Disaster drills at least every six months

STAFF/VOLUNTEER FILES

• Fingerprint clearance and or exemption

• LIC 9108 Statement Acknowledging Requirement to Report Child Abuse

• LIC 9052 Employee Rights

• Proof of current pediatric CPR and First Aid Certificates if transporting or licensee absence

• Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza

• TB clearance

• Mandated Reporter certificate – www.mandatedreporterca.com– must be renewed every two (2) years


Licensee Mahboubeh Ghiyasi was reminded that all adults 18 and over, living or working in the home, 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.
NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: William M Chancellor Jr.
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GHIYASI FAMILY CHILD CARE
FACILITY NUMBER: 376301165
VISIT DATE: 09/12/2025
NARRATIVE
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LPA discussed the safe sleep regulations with Licensee 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 as an additional resource. LPA also informed Licensee 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.

Licensee was reminded 15-sleep logs are required for all infants until the age of 24 months. LPA reminded licensee that sleep logs shall document the position of the infant, under the age of 12 months, and include staff initials. Documentation should reflect, date, times, child’s name, signs of distress and or labored breathing. When sleeping in a separate room the door must remain open; the provider should be able to visually observe the infant without moving the door. Additionally, pacifiers are allowed in the crib or play yard, with nothing attached Clothes clips are only permitted when the infant is mobile. Once the infant can climb out of a playpen, it is no longer appropriate, and the infant can transition out onto a cot or mat. The playpen must be kept free of all loose blankets.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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: https://www.ada.gov/resources/child-care-centers/

Licensee was informed of the MyChildCarePlan.org website; 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.

NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: William M Chancellor Jr.
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GHIYASI FAMILY CHILD CARE
FACILITY NUMBER: 376301165
VISIT DATE: 09/12/2025
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On-line Licensing forms & regulations for a Child Care Center and Family Child Care Home can be obtained on the Department’s website: www.ccld.ca.gov. Additionally, there is a link to “Receive Important Updates” located on the right side of the page, immediately above Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at: 951-782-4200. Unusual Incident Reports (UIR) must be called in within 24 hours and then electronically emailed or faxed within 7 business days at: unusualincidentreportsDO10@dss.ca.gov. Please refer to Title 22: 102416.2 Reporting Requirements- to reference mandatory reasons or incidents required to be self-reported to (CCL) in a timely manner.



On September 10, 2025, 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.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process for CARE tools, please send the email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

See LIC809-D for cited deficiencies.

Advisory notes (LIC 9102) were provided to review regulations that were observed to be either in question or a potential risk. Advisory Notes are provided with the intent to avoid issuing citations for violations that are technical in nature and do not present an immediate or potential health, safety or personal rights risk to those in care.

A Notice of Site Visit (NOS) was provided and must remain posted for 30 consecutive days. LPA reminded licensee that the NOS must be posted in a prominent space available to parents, guardians or care givers. An exit interview was conducted with Licensee Mahboubeh Ghiyasi. A copy of this report, along with appeal rights were discussed and provided during the exit interview.

NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: William M Chancellor Jr.
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
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