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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700268
Report Date: 02/04/2022
Date Signed: 02/04/2022 03:22:14 PM

Document Has Been Signed on 02/04/2022 03:22 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:GHOSH, REZYFACILITY NUMBER:
015700268
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 2CENSUS: 1DATE:
02/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Rezy GhoshTIME COMPLETED:
03:15 PM
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*THIS IS AN AMENDED DOCUMENT*

On 2/4/2022, Licensing Program Analyst (LPA) Jonathan Williams arrived to the facility unannounced for the purposes of conducting a Case Management inspection. LPA was met by Licensee, Rezy Ghosh. Present for today's inspection are the Licensee, the Licensee's fingerprint cleared and associated husband, and one child in care (infant). The purpose of today's visit is to place the backyard of the home on-limits.

LPA toured the backyard at 2:30pm. The backyard was observed to be free of loose, sharp, pointed, dangerous, or age-inappropriate items and furnishings at this time. There are no pools, ponds, hot tubs, or any other bodies of water in the backyard at this time. The outdoor side yards on both sides of the house shall remain off-limits to children, and LPA observed barricades preventing access to the side yards.

Backyard is placed on-limits as of today's inspection, dated 2/4/2022. Licensee is reminded that an inspection is required before any areas of the home marked "off-limits" can be placed "on-limits". Licensee is reminded that any structural changes or additions to the home must be reported to the Department.

Exit interview conducted. Appeal rights provided.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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