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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422337
Report Date: 07/21/2022
Date Signed: 07/21/2022 09:59:56 AM

Document Has Been Signed on 07/21/2022 09:59 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SHAH, HINAFACILITY NUMBER:
013422337
ADMINISTRATOR:SHAH, HINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 377-2622
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
07/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Hina ShahTIME COMPLETED:
10:15 AM
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On July 21, 2021 at approximately 9:45am LPA Haderer arrived unannounced and met with licensee for a Proof of Correction visit and to clear the deficiency. Present for the visit was the licensee and her fingerprint and TB cleared husband. There were no children in care at this time, the facility is closed this week for vacation.

Sleep logs were available and viewed thus clearing the deficiency. A Clearance letter was printed and issued.

A Notice of Site Visit was printed and must remain posted for 30 days.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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