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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004469
Report Date: 08/17/2021
Date Signed: 08/17/2021 11:53:01 AM

Document Has Been Signed on 08/17/2021 11:53 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.270
SACRAMENTO, CA 95833
FACILITY NAME:KUNZITE RESIDENTIAL INC.FACILITY NUMBER:
347004469
ADMINISTRATOR:ABRIAM, ZENAIDAFACILITY TYPE:
735
ADDRESS:9646 KUNZITE COURTTELEPHONE:
(916) 897-8801
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
08/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Zenaida TabhanTIME COMPLETED:
12:00 PM
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On 08/17/21, Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a case management visit to deliver an Order to Individual of Immediate Exclusion from Licensed Facilities and the Order To Licensee/Facility of Immediate Exclusion from Facility. LPA Valerio met with staff Zenaida T. and explained the purpose of the visit.  Staff (S1) is excluded from all Licensed Facilities.

LPA Valerio handed the Order To Licensee/Facility of Immediate Exclusion from Facility to staff Zenaida T. and explained that S1 would need to be removed from the facility immediately and S1 could not return to the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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