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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009337
Report Date: 10/16/2019
Date Signed: 10/18/2019 08:35:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ZAKI, SHERINE FCCHFACILITY NUMBER:
493009337
ADMINISTRATOR:ZAKI, SHERINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 280-3144
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:14CENSUS: 7DATE:
10/16/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Tamara Johnson- Licensee's assistantTIME COMPLETED:
03:25 PM
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An unannounced case management inspection visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang in response to the Licensee's outstanding Civil Penalty balance. The Licensee currently owes an outstanding Civil Penalty fee of $1000, which was assessed on 11/30/17.

During today's case management inspection visit, the licensee was not present at the facility. LPA met with the licensee's assistants, Tamara Johnson and Elizabeth Sanchez. At 02:00pm on 10/16/19, LPA called the licensee and spoke with the licensee over the telephone. LPA informed the licensee of the reason for the case management visit and informed the licensee that she currently has an overdue civil penalty fee of $1000, which was assessed on 11/30/19. LPA informed the licensee that a payment plan, which requires the licensee to pay at least ten percent of the outstanding civil penalty balance on a monthly basis is available. Licensee stated she understands and will pay the total balance of $1000 in full by 10/31/19. Licensee stated she understands that failure to pay the civil penalty will result in a Non-Compliance Conference and/or forfeiture of license.

This report was read and reviewed with the licensee's assistant, Tamara Johnson.

Notice of Site Visit shall be posted for 30 days from today's inspection.

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
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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