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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434402075
Report Date: 04/21/2021
Date Signed: 04/21/2021 01:46:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SUBZWARI, FARZANAFACILITY NUMBER:
434402075
ADMINISTRATOR:SUBZWARI, FARZANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 376-1196
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: 0DATE:
04/21/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Farzana SubzwariTIME COMPLETED:
01:43 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an announced Case Management- Licensee Initiated inspection. Due to COVID-19 and shelter in place, a tele-inspection was conducted via Facetime. LPA met with Licensee Farzana Subzwari and explained the reason for the inspection. The purpose of this inspection is Licensee requested to add the sun room to on-limits. LPA informed Licensee that a copy of this report dated 04/21/2021 will be emailed to her. Licensee's response to email will serve as acknowledgement that report was received.

Licensee guided LPA on tour of the sun room via Facetime. The room was observed to be safe for children to use. The off-limit areas inside the home are the two rooms, living room, and garage. An updated fire clearance to include the sun room was granted on 04/02/2021.
No deficiencies have been cited as a result of this inspection. A exit interview was conducted where this report was discussed and emailed to Licensee. A Notice of Site Visit has been issued and must be posted for 30 consecutive days.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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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