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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423671
Report Date: 12/01/2021
Date Signed: 12/01/2021 10:16:06 AM

Document Has Been Signed on 12/01/2021 10:16 AM - 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SHARIFI, SHADIFACILITY NUMBER:
013423671
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
12/01/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shadi SharifiTIME COMPLETED:
10:30 AM
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LPA L. Dyer conducted an announced pre-licensing inspection. Present for the inspection is applicant and her husband. Both are fingerprint cleared. This is the second inspection for this location. At the time of the first inspection, dated 11/03/21, it was requested that the applicant complete the following items to prepare the home to be licensed:
1. Fence box heater.
2. Remove branches in front yard.
3. Remove standing water in tub.
4. Block fireplace.
5. Move items in back yard.

A review of the items listed above has been completed. The applicant has:
1. Fenced box heater.
2. Removed branches.
3. Removed standing water in tub.
4. Blocked fireplace.
5. Removed items in back yard.

It is recommended that a license be issued to this Family Day Care Home pending receipt of all final clearances and the completion of all requirements. A license will be processed as soon as administratively possible.

Exit interview conducted. Appeal rights were discussed and given. This report must be available for public review for 3 years.
SUPERVISORS NAME: Phyllis Dyer
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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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