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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423671
Report Date: 03/03/2023
Date Signed: 03/03/2023 11:01:35 AM

Document Has Been Signed on 03/03/2023 11:01 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: 1DATE:
03/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Shadi SharifiTIME COMPLETED:
11:14 AM
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LPA L. Dyer met with Licensee Shadi Sharif for a Case Management Visit as a result of receiving an Unusual Incident Report. LPA toured the facility and interviews were conducted.

As a result of this visit, there are no deficiencies cited. Notice of Site Visit must be posted for 30 days. Exit interview conducted with Shadi Sharifi.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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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