Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372015741
Report Date: 04/21/2016
Date Signed 04/21/2016 08:46:58 AM

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:RAJPUT, IRFANA FAMILY CHILD CAREFACILITY NUMBER:
372015741
ADMINISTRATOR:IRFANA RAJPUTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 484-7621
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY:14CENSUS: 1DATE:
04/21/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Irfana RajputTIME COMPLETED:
09:00 AM
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An unannounced case management visit was conducted by LPA Gilbert Sena regarding a Case Closure Letter dated 04/05/16 for Adult #1. LPA met with Irfana Rajput, Licensee.

Licensee stated she was going to hire Adult #1 as an assistant; however Adult #1 decided not to complete the background process. Licensee stated Adult #1 has never worked or volunteered at the facility. Licensee stated she understands anyone who does not have a background clearance cannot live, work, or volunteer at the home.

No deficiencies cited.
SUPERVISOR'S NAME: Carol AugustTELEPHONE: (619) -76-2250
LICENSING EVALUATOR NAME: Gilbert SenaTELEPHONE: 619-767-2235
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2016
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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