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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623875
Report Date: 05/28/2021
Date Signed: 05/28/2021 02:32:15 PM

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:4TH R - PASO VERDEFACILITY NUMBER:
343623875
ADMINISTRATOR:DJALILI, MARIAFACILITY TYPE:
840
ADDRESS:3883 DEL PASO ROADTELEPHONE:
(916) 566-4496
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY:150CENSUS: 56DATE:
05/28/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Maria DjaliliTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Christopher Bello met with the Program Coordinator Maria Djalili for an unannounced Case Management Licensee Initiated tele-inspection using the FaceTime application. Today’s inspection regarded adding two portables (W1 and W2) for facility use. LPA inspected the portables during the inspection and observed that they were in compliance with Title 22 regulations and the Health and Safety Code.


Effective today 5/28/2021, approved for use of the portables W1 and W2.


No Title 22 Deficiencies observed in the areas that were evaluated. LPA reviewed report with the director and provided copies. LPA reviewed report and provided copies of the report, Notice of Site Visit and appeal rights via email. The licensee will send an email back stating that they received the documents to act as their virtual signature.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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