Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618345
Report Date: 08/14/2019
Date Signed: 08/14/2019 11:51:31 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.250
SACRAMENTO, CA 95833
FACILITY NAME:MAZLOOM, ZIBAFACILITY NUMBER:
343618345
ADMINISTRATOR:MAZLOOM, ZIBAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 990-4894
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:14CENSUS: 5DATE:
08/14/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Ziba Mazloom, LicenseeTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Kelly Ferrara and Mai Lor met with Licensee Ziba Mazloom and advised her that today's inspection was to verify correction of deficiencies that were cited on July 12th, 2019 with a due date of August 12th, 2019. At the time of the inspection, the census was five children present with the Licensee.

Licensee showed the LPAs her gun safe and LPAs were able to observe that the firearms were stored according to regulations. LPAs were able to clear the deficiency and provided a letter to Licensee as proof.

LPAs reviewed children's files and observed that each child enrolled in care had the correct documentation including Medical Consent form and Notification of Parent's Rights forms. LPA Ferrara received copies of Licensee's immunization record via email and LPA was able to observe immunity to Measles, Mumps, Rubella, and Pertussis. LPAs were able to clear the deficiencies and provided a letter to Licensee as proof.

Exit interview was conducted and Notice of Site visit was posted.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
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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