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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622691
Report Date: 07/06/2023
Date Signed: 07/06/2023 09:22:02 AM


Document Has Been Signed on 07/06/2023 09:22 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ESMAIL, EZDIHARFACILITY NUMBER:
343622691
ADMINISTRATOR:ESMAIL, EZDIHARFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 624-0366
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:14CENSUS: DATE:
07/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ezdihar EsmailTIME COMPLETED:
09:25 AM
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On 7/6/2023, Licensing Program Analysts (LPAs) Jennie Tedlos and Lauren Scott conducted a Case Management Inspection for the purpose of making an off limit area in the facility on limits. LPA met with Licensee Ezdihar Esmail.

LPA and Licensee toured the home. LPA was shown the areas that Licensee is requesting to be on limits. The licensee is requesting the kitchen, living room, and dining room to go from off-limits to on-limits. Current off limit areas of the facility will now be: entire upstairs, and the storage shed outside.

In the areas that were evaluated today, no deficiencies were observed. An exit interview was conducted and Notice of Site Visit was posted by LPA and must remain posted for 30 days. A failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 215-3003
LICENSING EVALUATOR NAME: Jennie TedlosTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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