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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100500
Report Date: 10/14/2022
Date Signed: 10/14/2022 03:34:30 PM

Document Has Been Signed on 10/14/2022 03:34 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:SHARIF MOUSAVI, SARA & KHATAMI, SEYEDEHSARA FCCFACILITY NUMBER:
376100500
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
10/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licesee Sara Sharif MousaviTIME COMPLETED:
03:30 PM
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On 10/14/2022 @ 3:00 p.m., Licensing Program Analyst (LPA), Joelle Redding, made an unannounced visit to evaluate the facility for a requested increase in capacity. Application was received on 8/15/22. Fire clearance was granted on 10/3/22. Licensee Seyedehsara Khatami was out of of the country visiting family at this time. This visit was conducted with LIcensee Sara Sharif Mousavi.

LPA toured the home and verified the on/off limits areas. A sample of children's files were reviewed. No roster was on file. All adults in the home have been fingerprint cleared and associated. TB clearances and LIC 508s were on file. Current EMSA certified First Aid/CPR certification was verified for Licensee Sara, however Licensee Seyedehsara was not present to verify. She is expected to be out of the country for approximately 6 more months. Licensee Sara will contact her for verification of completion.

Capacity limitations were discussed today. Licensee understands that she may only operate at the Large Family Home capacity when an assistant or the co-licensee is available. Otherwise, she must adhere to the limits of the Small Family Home capacity.

Upon receipt of the updated roster, the request increase in capacity is granted and an updated license will be sent for posting.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Joelle Redding
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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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