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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405959
Report Date: 08/03/2023
Date Signed: 08/03/2023 11:51:59 AM


Document Has Been Signed on 08/03/2023 11:51 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:KAZMI, SARAHFACILITY NUMBER:
073405959
ADMINISTRATOR:KAZMI, SARAHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 245-0678
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:14CENSUS: 7DATE:
08/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:KAZMI, SARAH TIME COMPLETED:
12:10 PM
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On August 3, 2023, at 8:35AM Licensing Program Analyst (LPA) Nyeesha Blount and Christina Watts met with Kazmi, Sarah, for an unannounced case management visit. The purpose of today’s visit was to follow up on unusual incident report.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Kazmi, Sarah.

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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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