<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
125407570
Report Date:
04/04/2022
Date Signed:
04/04/2022 12:09:22 PM
Document Has Been Signed on
04/04/2022 12:09 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:
PEREZ, JENSHEN FAMILY CHILD CARE HOME
FACILITY NUMBER:
125407570
ADMINISTRATOR:
PEREZ, JENSHEN
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(707) 798-7102
CITY:
EUREKA
STATE:
CA
ZIP CODE:
95503
CAPACITY:
14
CENSUS:
8
DATE:
04/04/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
11:45 AM
MET WITH:
Jenshen Perez
TIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Lynch met with Licensee to amend a report from last week to remove LPA typo errors from report. No deficiencies cited during today's visit.
SUPERVISOR'S NAME:
Erin Virrueta
TELEPHONE:
(530) 895-4325
LICENSING EVALUATOR NAME:
Kiriko Lynch
TELEPHONE:
(530) 895-5033
LICENSING EVALUATOR SIGNATURE:
DATE:
04/04/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1