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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200822
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:03:41 PM

Document Has Been Signed on 11/17/2022 03:03 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. 310
OAKLAND, CA 94612
FACILITY NAME:HOME SWEET HOME OF HERCULESFACILITY NUMBER:
079200822
ADMINISTRATOR:DASTGHEIB, ALI SINAFACILITY TYPE:
740
ADDRESS:295 SPARROW DRTELEPHONE:
(510) 245-2948
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 6DATE:
11/17/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Elizabeth Zamora, CaregiverTIME COMPLETED:
03:15 PM
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On 11/17/2022 approximately 2:20PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct a proof of correction (POC) visit for the deficiency cited on 09/29/2022. LPA met with caregiver Elizabeth Zamora and explained the purpose of the visit.

LPA observed the shed located in the backyard as being used as what it is intended for storage, LPA observed items such as wheel chair, lamp, shower chair, drawers, cabinet and boxes.

No deficiencies are being cited on this date.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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