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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 163901684
Report Date: 12/04/2019
Date Signed: 12/04/2019 11:59:15 AM

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:MOMBERGER, DAWN FAMILY CHILD CAREFACILITY NUMBER:
163901684
ADMINISTRATOR:MOMBERGER, DAWNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 925-1680
CITY:LEMOORESTATE: CAZIP CODE:
93245
CAPACITY:14CENSUS: 7DATE:
12/04/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Dawn MombergerTIME COMPLETED:
12:10 PM
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On this date, Licensing Program Analysts (LPAs) Ruby Ocegueda and Robert Gutierrez conducted an unannounced case management inspection and met with licensee Dawn Momberger. The purpose for the case managment inspection today was to communicate to licensee Momberger that her adult son (adult #1) has "No Action" indication under the Child Abuse Index on LIS form 531. Adult #1 currently does not live in the home. Today, LPA's advised licensee that her son adult #1 should be re-fingerprinted if licensee wanted to continue to have adult #1 associated to the facility. Licensee stated that she would be getting her son adult #1 re-fingerprinted.

LPA obtained licensee's new cell number and email information today and will be updated in our department system. LPA reminded licensee to please update our department with any updated telephone contact information in the future.
SUPERVISOR'S NAME: Michael DuarteTELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Ruby OceguedaTELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
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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