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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402205
Report Date: 03/04/2022
Date Signed: 03/04/2022 09:58:22 AM


Document Has Been Signed on 03/04/2022 09:58 AM - 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:RAMIREZ, ROSALBAFACILITY NUMBER:
073402205
ADMINISTRATOR:RAMIREZ, ROSALBAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 741-7848
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:14CENSUS: 1DATE:
03/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:David ValenciaTIME COMPLETED:
10:00 AM
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On 3/4/22, at 9:33AM, Licensing Program Analysts (LPAs) Catherine Fernandes and Indira Loza arrived on a case management visit. There was one infant in care.

LPAs met with David Valencia and spoke to Licensee Rosalba Ramirez via telephone. While at the home LPAs provided a list of documents to update the home's file.






Exit interview conducted with David
Notice of site visit provided.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine FernandesTELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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