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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
115408087
Report Date:
04/14/2022
Date Signed:
04/14/2022 02:12:43 PM
Document Has Been Signed on
04/14/2022 02:12 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
,
520 COHASSET RD., SUITE 170
CHICO
,
CA
95926
FACILITY NAME:
ROMO-RIVERA, YESMIN FAMILY CHILD CARE HOME
FACILITY NUMBER:
115408087
ADMINISTRATOR:
ROMO-RIVERA, YESMIN
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(530) 513-4769
CITY:
ORLAND
STATE:
CA
ZIP CODE:
95963
CAPACITY:
14
CENSUS:
2
DATE:
04/14/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
11:00 AM
MET WITH:
Yesmin Romo Rivera
TIME COMPLETED:
11:05 AM
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Case management was completed to complete inspection tool.
SUPERVISOR'S NAME:
Megan Aviles
TELEPHONE:
(530) 895-5984
LICENSING EVALUATOR NAME:
Bianca Mendez
TELEPHONE:
(530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE:
04/14/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/14/2022
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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