<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700094
Report Date: 12/10/2021
Date Signed: 12/10/2021 11:40:05 AM

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:
12/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee, Miriam Aziz TIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced case management visit at facility on December 10, 2021 at 11:15 a.m. for the proceeding of the facility closure. LPA met with Licensee Miriam Aziz and explained the purpose for today's visit. A Notice of Facility Closure was received by the LPA on 12/02/2021 with a facility closure date of 12/10/2021. Licensee has no residents living at the facility currently..
LPA observed interior/exterior of the facility, including front and back yards, living room, dining room, kitchen, bathrooms, and all bedrooms. LPA observed that there were no residents at the facility.

LPA retrieved original license and informed Licensee Miriam Aziz that the facility will be closed in the system as of 12/10/2021. A copy of this report was left with Licensee Miriam Aziz.

Link to survey for Facility Closure provided to Licensee Miriam Aziz.

www.surveymonkey.com/r/facilityclosure


Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1