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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125407570
Report Date: 04/04/2022
Date Signed: 04/04/2022 12:10:23 PM


Document Has Been Signed on 04/04/2022 12:10 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 HOMEFACILITY NUMBER:
125407570
ADMINISTRATOR:PEREZ, JENSHENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 798-7102
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:14CENSUS: 8DATE:
04/04/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jenshen PerezTIME COMPLETED:
12:15 PM
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LPA Lynch met with Licensee for the purpose of a POC inspection visit. LPA observed Licensee and assistant were supervising 8 children at 11:45 AM, and care and supervision and ratio requirements were met during the visit. POC cleared during today's visit. No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (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)
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