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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573617483
Report Date: 12/13/2022
Date Signed: 12/13/2022 01:50:26 PM


Document Has Been Signed on 12/13/2022 01:50 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:MUSALLAM, ABEERFACILITY NUMBER:
573617483
ADMINISTRATOR:MUSALLAM, ABEERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 743-7417
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:14CENSUS: DATE:
12/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Abeer MusallamTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erwin Tjhia met with the Licensee, Abeer Musallam to follow up on the Unusual Incident Report (UIR) submitted to Community Care Licensing on 11/03/2022. During today's visit LPA toured the facility, observed the care and supervision of children

Licensing staff discuss a UIR that was submitted to the office by the licensee that a child sustained an injury of a broken arm. A police report was obtained, and it was determined that the injury did not occur at the family childcare home

No deficiencies were cited during this visit.

An Exit interview was conducted. A Notice of Site Visit was posted by licensing staff and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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