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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624549
Report Date: 01/10/2024
Date Signed: 01/10/2024 09:46:05 AM

Document Has Been Signed on 01/10/2024 09:46 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FAIZI, PALWASHAFACILITY NUMBER:
343624549
ADMINISTRATOR:FAIZI, PALWASHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 907-5860
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
01/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Palwasha FaiziTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christopher Bello arrived at the facility at approximately 8:30am and met with licensee Palwasha Faizi regarding an Case Management Deficiencies inspection. No daycare children were present at time of inspection. Also present was licensee’s minor children and husband. LPA observed on 12/19/2023 the facility did not have LIC9149 on file. This is considered as a potential risk to the children in care. LPA printed and provided LIC9149.

In the areas that were evaluated, deficiency was observed at the time of the visit and cited on LIC 809D. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee [or facility representative] Palwasha Faizi.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Christopher Bello
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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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Document Has Been Signed on 01/10/2024 09:46 AM - It Cannot Be Edited


Created By: Christopher Bello On 01/10/2024 at 09:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FAIZI, PALWASHA
FACILITY NUMBER: 343624549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2024
Section Cited
CCR
102417(q)(1)

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The licensee shall maintain the original of the completed and signed LIC 9149 (Rev. 8/14) Property Owner/Landlord Consent, which is incorporated by reference, attached to the Family Child Care Home’s license on file in the home. This requirement has not been met by evidence: LPA did not observe
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Licensee will submit signed LIC9149 to LPA by POC date 2/9/24 or notify licensee that they cannot get consent from property owner.
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LIC9149 on file. This is considered as a potential risk to the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Amanda Blesi
LICENSING EVALUATOR NAME:Christopher Bello
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024


LIC809 (FAS) - (06/04)
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