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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103901483
Report Date: 08/19/2019
Date Signed: 08/19/2019 08:31:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:MORENO, AGUSTINA FAMILY CHILD CAREFACILITY NUMBER:
103901483
ADMINISTRATOR:MORENO,AGUSTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 626-7134
CITY:ORANGE COVESTATE: CAZIP CODE:
93646
CAPACITY:14CENSUS: 6DATE:
08/19/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Agustina MorenoTIME COMPLETED:
03:40 PM
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LPA Diana Martinez conducted an unannounced case management inspection today and was met by licensee Agustina Moreno. There were six day care children present today. The purpose of today's inspection was to inspect the wooden play structure recently installed in the backyard for day care children’s use. Areas under and around play structure have sufficient bark cushioning material to absorb falls. LPA observed that backyard is free of hazards that may endanger day care children. Safe outdoor toys are in the backyard and no bodies of water observed. Wooden play structure is approved for use effective today, 8/19/19.

Per California Code of Regulations, Title 22, Division 12, Chapter 3, no deficiencies cited during today's visit.

An exit interview conducted with licensee Agustina Moreno and a copy of this report was provided and discussed. A Notice of Site Visit Form (LIC 9213) was posted on parent's board and must remain posted for 30 days.
SUPERVISOR'S NAME: Michael DuarteTELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Diana D MartinezTELEPHONE: (559) 341-4670
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2019
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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