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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619976
Report Date: 10/29/2021
Date Signed: 10/29/2021 08:46:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:IBRAHIM, HUNERAFACILITY NUMBER:
343619976
ADMINISTRATOR:IBRAHIM, HUNERAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 689-6073
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:14CENSUS: 5DATE:
10/29/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Hunera IbrahimTIME COMPLETED:
08:50 AM
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On 10/29/2021 at 8:29 AM Licensing Program Analyst (LPA) Jeevun Birk-Miller conducted an unannounced case management inspection and met with Licensee, Hunera Ibrahim. The purpose of the inspection was to make the back yard off-limits. The Licensee is adding a sun room to the home. Licensee understands that children are not to be in the off-limits area while construction of the sun room is occurring and notify Licensing when complete. Off-limits areas will remain inaccessible to children by closed doors and/or supervision.

At this no citations were given and an exit interview was conducted. A Notice of Site Visit was given and posted. This shall be posted for 30 days.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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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