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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201259
Report Date: 04/14/2023
Date Signed: 04/27/2023 01:58:02 PM

Document Has Been Signed on 04/27/2023 01:58 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:HEAVENLY CARE HOMEFACILITY NUMBER:
019201259
ADMINISTRATOR:ABBASI, SHAHIDFACILITY TYPE:
740
ADDRESS:36857 WALNUT ST.TELEPHONE:
(925) 963-4081
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 0DATE:
04/14/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Bushra Shahid CEO; Shahid Abbasi AdministratorTIME COMPLETED:
02:38 PM
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Component II completion: Successful

Facility Type: RCFE
Application Type: INITIAL
Capacity: 6
Census (if any clients in care): 0

COMP II Participants: Bushra Shahid CEO/ Shahid Abbasi Administrator
Interview Method: Telephone interview

On April 14, 2023, Applicant/Administrator participated in COMP II. Identification of the
applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/ administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the
following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-Licensing Readiness
SUPERVISORS NAME: Tracy Thompson
LICENSING EVALUATOR NAME: Ricmar Soriano
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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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