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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700611
Report Date: 06/25/2021
Date Signed: 06/25/2021 03:48:30 PM

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:QURESHI CARE HOMEFACILITY NUMBER:
392700611
ADMINISTRATOR:UMER QURESHI, MUHAMMADFACILITY TYPE:
735
ADDRESS:9555 PRISCILLA LANETELEPHONE:
(209) 224-1948
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:5CENSUS: 5DATE:
06/25/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Umer QureshiTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA's ) Ashley Boothe and Michael Bilger conducted a case management visit to the facility on today's date for the purpose of delivering an Order to to Licensee/Facility of Immediate Exclusion From Facility for all facilities for Person one (P1).

LPA's met with Umer Qureshi, and explained the purpose of today's visit. P1 is excluded as a result of actions related to this facility. P1 was terminated on 12/26/2020 and LPA's observed P1 was not present in the facility during today's visit.

LPA's handed the Order to to Licensee/Facility of Immediate Exclusion From Facility and explained that P1 cannot come to the facility and cannot be allowed to work, be present and/or live in a CCL licensed facility or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services.

Exit interview conducted, a copy of this report provided. A signature on these forms acknowledges receipt of these forms.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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