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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001110
Report Date: 11/29/2022
Date Signed: 11/29/2022 01:53:15 PM


Document Has Been Signed on 11/29/2022 01:53 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:FARD-RAMEZANI, HOMAFACILITY NUMBER:
414001110
ADMINISTRATOR:FARD-RAMEZANI, HOMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 835-4662
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:14CENSUS: 0DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee, Homa Fard-RamezaniTIME COMPLETED:
02:15 PM
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On November 29th, 2022 at approximately 1:15pm, Licensing Program Analyst (LPA) Tapia-Mandujano arrived at the facility to conduct an unannounced required annual inspection. Purpose of the inspection was explained. LPA met with licensee, Homa Fard-Ramezani. Present in the home is licensee and husband. Licensee stated that she has not cared for children since May 2022 due to health related concerns. Licensee has decided to place her license in "inactive" status. Once the inactive status expires, she will contact CCLD. LIC 9211 - Request for Inactive Status form was printed for licensee and a original copy was received by LPA.

Copy of this report was provided to licensee and will be public for review. Desk Duty is available Monday through Friday between 8:00 AM - 5:00 PM at (650) 266-8800. Website for forms and Regulations: www.cdss.ca.gov.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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