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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394501130
Report Date: 06/12/2024
Date Signed: 06/12/2024 04:05:36 PM

Document Has Been Signed on 06/12/2024 04:05 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ZUBAIR, FRESHTAFACILITY NUMBER:
394501130
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Licensee Freshta ZubairTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On 6/12/24, Licensing Program Analyst (LPA) Carla Polanco Rivera met with Licensee Freshta Zubair. LPA was granted entrance to the facility. The purpose of today’s case management visit was to update the facility and add additional adults that reside in the home.

This report along with the application was reviewed 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.


During today's inspection License was notified that a Type-A deficiency was cited on a subsequent 9099-D page.

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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