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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416470
Report Date: 12/01/2022
Date Signed: 12/01/2022 10:38:36 AM

Document Has Been Signed on 12/01/2022 10:38 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MARJI, SABREENFACILITY NUMBER:
434416470
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
12/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marji, SabreenTIME COMPLETED:
10:28 AM
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On this day Licensing Program Analyst Almaraz, Celi conducted an unannounced case management visit. Due to COVID- 19 precautionary measures were taken, licensing staff present during visit wore appropriate personal protective equipment. The purpose of this visit to amend a report dated 11/29/2022. An LIC 9099 was issued during visit and signature was obtained.

There are no deficiencies being cited in accordance with Title 22 of the California Code of Regulations and Health & Safety codes.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Araceli Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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