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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009337
Report Date: 05/19/2023
Date Signed: 05/19/2023 04:44:18 PM


Document Has Been Signed on 05/19/2023 04:44 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 0DATE:
05/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:N/ATIME COMPLETED:
01:01 PM
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A case management visit was made to the facility today by Licensing Program Analyst (LPA) Y.Yang to conduct a confirmation of facility closure visit. The facility's licensee, Sherine Zaki submitted a change of location application on 4/11/23. The licensee's new facility (facility# 493010414) was licensed as of 5/15/23.

During today's case management visit, the LPA observed no children in care or any evidence of childcare being provided at this address. The licensee was not present during this visit. The curtains of the home were open and the interior of the home appeared to be empty and the home vacant.

Confirmation of facility closure is complete.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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