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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500204
Report Date: 04/13/2023
Date Signed: 04/14/2023 03:42:14 PM

Document Has Been Signed on 04/14/2023 03:42 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
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:MUSTAFA, HUMAFACILITY NUMBER:
344500204
ADMINISTRATOR:AHMED, SHABANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 271-7575
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
04/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Huma MustafaTIME COMPLETED:
12:00 PM
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++++ This is an amended report of a version originally written on 4/13/2023 ++++++

Licensing Program Analyst (LPA) David Nguyen met with Licensee, Huma Mustafa to follow up on the Unusual Incident Reports (UIRs) submitted to Community Care Licensing on March 23rd, 2023.

LPA toured the facility, observed the care and supervision of children, reviewed records and conducted interviews.

Facility evaluation report was reviewed and discussed with Licensee. Exit interview was conducted. A Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
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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