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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403322
Report Date: 03/09/2023
Date Signed: 03/13/2023 09:55:38 PM

Document Has Been Signed on 03/13/2023 09:55 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:AKBARI-FEO, MARIAFACILITY NUMBER:
434403322
ADMINISTRATOR:AKBARI-FEO-, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 371-7863
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
03/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 AM
MET WITH:Maria Akbari-FeoTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Berumen conducted a case management inspection. LPA observed 11 children in care (five infants and 6 pre-schoolers) in care today.

Based on observations and file review; Licensee is operating out of capacity and not conducting and documenting 15 minute sleep checks for infants (0-24 months).

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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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Document Has Been Signed on 03/13/2023 09:55 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 03/09/2023 at 11:09 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AKBARI-FEO, MARIA
FACILITY NUMBER: 434403322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2023
Section Cited
CCR
102416.5(d)(1)

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STAFFING RATIO AND CAPACITY

Twelve children, no more than four of whom may be infants;
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Licensee states that she will submit a written plan of correction indicating which infant will no longer be in care and also add in her statement that she understands regulation section 102416.5. Licensee will also attend a informal meeting with Management.
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This requirement was not met as evidenced by: Licensee was caring for five infants. Which poses a immidiate health, safety risk to children in care.
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“Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.”

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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.
SUPERVISOR'S NAME:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/13/2023 09:55 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 03/09/2023 at 12:36 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AKBARI-FEO, MARIA
FACILITY NUMBER: 434403322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited
CCR
102425(j)(2)

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INFANT SAFE SLEEP
The provider shall supervise infants while they are sleeping and adhere to the following requirements: (1) The provider shall physically check on the infant every 15 minutes.
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Licensee agrees to submit sleeping logs for infants in care by plan of correction date of 03/16/2023. Licensee to also read section 102425 and state she understands the safe sleep regulation.
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Based on record review, the licensee did not comply with the section cited above as all five infants under 2 years old were missing 15 min. check sleeping logs in which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023


LIC809 (FAS) - (06/04)
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