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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434402075
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:44:42 PM

Document Has Been Signed on 08/04/2022 03:44 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SUBZWARI, FARZANAFACILITY NUMBER:
434402075
ADMINISTRATOR:SUBZWARI, FARZANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 376-1196
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 3DATE:
08/04/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Farzana SubzwariTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA), James Santos arrived at the home today for the continuation of the annual inspection. LPA met with Licensee, Farzana Subzwari.

Licensee's records were reviewed. Licensee's CPR/1st Aid certification is valid through April 2023 and her Mandated Reporter Training certification is valid through July 2024. Emergency drills are conducted every 6 months. Per the documentation, the last drill was conducted in April 2022.

Per Licensee, she does not transport children and currently does not have any children in care who requires Incidental Medical Services. LPA discussed and provided a copyof the Safe Sleep Regulation with Licensee.

LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Care providers are encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online Licensing Forms, Adoption of new Laws, etc.

No deficiencies cited during today's inspection. Exit interview conducted and report was reviewed and a copy of the report was provided to Licensee.


NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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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