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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009337
Report Date: 11/12/2019
Date Signed: 11/13/2019 08:16:45 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:
11/12/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Sherine ZakiTIME COMPLETED:
10:57 AM
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An unannounced, follow-up 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 a previous case management visit to the facility on 10/16/19, the licensee stated that she would pay off the balance of the civil penalty by 10/31/19. Licensee stated that she was unable to pay by this date due to an unforeseen circumstance. The licensee is requesting an extension to pay off the balance of the civil penalty.

During today's case management visit, LPA created a Payment Plan Agreement with the licensee. The licensee stated that she will make her first payment of $250 on or before 11/20/19. The licensee stated that the second payment of $250 will be made on or before 12/01/19, the third payment of $250 will be made on or before 12/20/19, and the final payment of $250 will be made on or before 01/03/20. Checks must be mailed or delivered to the Rohnert Park Regional Office and shall include the civil penalty invoice number(s) and facility number. 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. 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: 11/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2019
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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