<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624113
Report Date: 08/09/2022
Date Signed: 08/09/2022 09:53:51 AM

Document Has Been Signed on 08/09/2022 09:53 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:SHAREGHI, MEHRIFACILITY NUMBER:
343624113
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/09/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mehri ShareghiTIME COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On August 9, 2022, at approximately 9:30 AM, Licensing Program Analyst (LPA) Alize Tillery made an unannounced visit to the facility. Upon arrival, there were no children present. Licensee has requested that the previously off limit area: backyard - be placed on limits.

LPA toured the home and observed the backyard area. LPA has observed that Licensee has blocked off the basement area, fixed the stairs leading down to the backyard and removed hazardous items.

As of today, 8/9/2022, backyard is on limits and the children may enter this area. Off limit areas consist of: bedroom #2 and basement.

In the areas observed, no deficiencies were cited. LPA reviewed report with Licensee and provided a notice of site visit, which is to remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1