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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202589
Report Date: 02/13/2024
Date Signed: 02/13/2024 02:32:23 PM

Document Has Been Signed on 02/13/2024 02:32 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MUNA'S CARE HOME IIIFACILITY NUMBER:
435202589
ADMINISTRATOR:SEDIGH, TAYEBEHFACILITY TYPE:
735
ADDRESS:275 MORAGA WAYTELEPHONE:
(408) 856-5115
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 6DATE:
02/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator, Tayebeh SedighTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit and met with Administrator (ADM) Tayebeh Sedigh. LPA Rai was to conduct a 1-Year Inspection but it was already conducted yesterday 2/12/2024.

ADM stated the requested paperwork was mailed to the San Bruno Regional Office - San Jose Office.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM) Tayebeh Sedigh. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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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