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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700094
Report Date: 09/15/2021
Date Signed: 11/02/2021 04:28:36 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:HUMMINGBIRD MANORFACILITY NUMBER:
502700094
ADMINISTRATOR:AZIZ, MARIAMFACILITY TYPE:
740
ADDRESS:3205 HUMMINGBIRD LNTELEPHONE:
(209) 521-4411
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 0DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Mariam AzizTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facilities annual inspection. LPA met with Administrator Mariam Aziz Administrator's Certification expires 04/24/2022. There are currently 0 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair.There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.


There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator and copy of report left at facility


Administrator will notify LPA when she decides to populate the facility with residents again.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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