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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623657
Report Date: 08/02/2024
Date Signed: 08/02/2024 04:24:51 PM

Document Has Been Signed on 08/02/2024 04:24 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NIKBEEN, MARZIAFACILITY NUMBER:
343623657
ADMINISTRATOR/
DIRECTOR:		NIKBEEN, MARZIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 835-2948
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
08/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Mohammad NikbeenTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On August 2, 2024, at approximately 2:05 PM, Licensing Program Analyst (LPA) Josiah Gathing met with Facility Representative Mohammad Nikbeen for a case management inspection. Upon arrival, LPA observed 9 children supervised by Facility Representative Mohammad Nikbeen and his child (age 14). Nikbeen explained that his spouse, the Licensee, was at a doctor's appointment and would be away from home until later. LPA inquired if Mohammad Nikbeen had completed Pediatric CPR training. Nikbeen stated that he did not complete CPR. Licensee Marzia Nikbeen arrived at home during today's inspection.

A deficiency is cited on the following page. LPA reviewed and printed this report for the Facility Representative. A Notice of Site Visit was provided and must remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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 08/02/2024 04:24 PM - It Cannot Be Edited


Created By: Josiah Gathing On 08/02/2024 at 03:12 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NIKBEEN, MARZIA
FACILITY NUMBER: 343623657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
102416(c)

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102416 Personnel Requirements (c) The licensee and other personnel as specified shall complete training... including pediatric cardiopulmonary resuscitation and pediatric first aid...
This standard was not met as evidenced by:
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Facility Representative will provide proof of current EMSA approved Pediatric CPR and First Aid to Licensing Program Analyst by Plan of Correction date.
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Based on record review the facility did not comply with the above regulation as no present personnel had current Pediatric CPR on file which poses 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:Seychelle De Luca
LICENSING EVALUATOR NAME:Josiah Gathing
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
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