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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415249
Report Date: 11/30/2022
Date Signed: 11/30/2022 04:06:07 PM


Document Has Been Signed on 11/30/2022 04:06 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:SOROYA, SHAZIAFACILITY NUMBER:
434415249
ADMINISTRATOR:SOROYA, SHAZIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 887-2471
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY:14CENSUS: 1DATE:
11/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Shazia SoroyaTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Mel Matos met with Shazia Soroya, Licensee, for an unannounced case management inspection. LPA also observed two of Licensee's minor children, ages 11 & 2 1/2 years, in the home during today's inspection.

No day care children were present during today's inspection. Licensee states that she has not had children enrolled in the day care since. Licensee states that she wishes to keep her license active at this time in case she enrolls children in the future.

LPA provided the Licensee with a copy of the Safe Sleep regulations as well as a copy of the Individual Infant Sleeping Plan (LIC 9227). LPA reminded the Licensee that she will need to provide the Individual Infant Sleeping Plan (LIC 9227) to parent(s) of any enrolled child(ren) under one year of age at time of enrollment.

Exit interview conducted and report was reviewed with the Licensee, Shazia Soroya. No deficiencies issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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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