<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314112
Report Date: 10/08/2024
Date Signed: 10/08/2024 11:12:06 AM

Document Has Been Signed on 10/08/2024 11:12 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:AKHAVAN, MAHJABINFACILITY NUMBER:
304314112
ADMINISTRATOR/
DIRECTOR:		AKHAVAN, MAHJABINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 742-2581
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
10/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Licensee Akhavan, MahjabinTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/8/2024 at 7:00am, Licensing Program Analysts (LPAs), Jung and Tran conducted an unannounced case management – plan of correction inspection.

Approximately 8:30am, LPAs observed Child 1 (C1) being dropped off by Parent 1 (P1).

Approximately 9:00am, LPAs approached the home and knocked on the front door. While waiting at the door, at approximately 9:05am, LPAs observed Parent 2 (P2) attempting to drop off Child 2 (C2). P2 noticed LPAs and took their child back to the car where they waited.

Approximately 9:10am, Adult 1 (A1) answered the door. A1 informed LPA Jung that they spent the night at the facility and was waiting for the licensee to arrive. A1 stated that facility hours start at 10am, so they switch off with the licensee in the mornings for daycare hours. A1 stated that daycare hours had not been updated with the Regional Office (RO). A1 stated that C2 was waiting outside with P2 until licensee arrives. A1 stated they were supervising C1 in the facility, in addition to their biological child.

LPAs waited outside the front door for licensee to arrive. Approximately 9:45am, LPAs were allowed into the home by A1. A few minutes after entering the facility, the licensee arrived and entered the home with C2. Once licensee arrived, A1 left the facility.

Licensee confirmed with LPAs that A1 was present in the facility without their background clearance as of today for about 1.5 hours, despite what was stated in their plan of correction for the deficiency dated 9/18/24 in which the licensee provided a declaration stating A1 and A2 will not be present at the facility during facility hours without background clearance.
(Go to Page 2)
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: AKHAVAN, MAHJABIN
FACILITY NUMBER: 304314112
VISIT DATE: 10/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Page 2)
During their interview with LPAs, licensee provided a declaration stating that they wish to surrender their license and only provide care through the end of the current week. LPAs confirmed that as of 10/12/2024, their licensee will be surrendered to RO and facility will be closed.

Based on LPAs observation, interview, and record review, the licensee did not comply with the plan of correction agreed upon on 9/18/2024 and had an uncleared adult in the facility, which poses an immediate health, safety or personal rights risk to persons in care; see LIC 809D for deficiency.

LPAs Jung and Tran informed licensee that this report dated 10/8/2024 documents 1 type A citation. Type A citation shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPAs Jung and Tran informed the licensee to provide a copy of this licensing report dated 10/8/2024 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Report was translated in Farsi by LPA Malek.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Akhavan, Mahjabin.

(End of Report)
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/08/2024 11:12 AM - It Cannot Be Edited


Created By: Soo Jin Jung On 10/08/2024 at 10:46 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: AKHAVAN, MAHJABIN
FACILITY NUMBER: 304314112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2024
Section Cited
HSC
1596.871(c)(1)(A)

1
2
3
4
5
6
7
1596.871(c)(1)(A) Fingerprints and criminal record information of individuals in contact with child day care facility clients: a person...shall obtain...a criminal record clearance...prior to...presence in the facility. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee provided a declaration stating that they would close the facility by the end of the week and will surrender their license to RO effective 10/12/2024.
8
9
10
11
12
13
14
Based on observation, interviews, and record reviews, the licensee did not ensure all adults in the facility were background checked prior to being in the facility which poses an immediate risk to the health, safety, and personal rights of the clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Martha Malane
LICENSING EVALUATOR NAME:Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3