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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416851
Report Date: 05/20/2019
Date Signed: 05/20/2019 03:07:17 PM

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:VERGARA, ANGELAFACILITY NUMBER:
013416851
ADMINISTRATOR:VERGARA, ANGELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 477-9129
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:14CENSUS: 12DATE:
05/20/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Angela VergaraTIME COMPLETED:
03:30 PM
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On 05/20/19, Licensing Program Analysts Briana Plumboy and Melissa Guirit met with licensee Angela Vergara for an UNANNOUNCED RANDOM INSPECTION. Present for this visit was 12 preschool age children in care and licensees teenage daughter who is assisting with the child care. The home was toured and a census was taken.

A POC letter was issued to the licensee today. The licensee is in ratio today.

There are no deficiencies cited. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019
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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