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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 163910602
Report Date: 06/19/2019
Date Signed: 06/19/2019 12:35:41 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:MARTINEZ, MARIA FAMILY CHILD CAREFACILITY NUMBER:
163910602
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
06/19/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Maria MartinezTIME COMPLETED:
11:15 AM
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On this date, Licensing Program Analyst (LPA) Kathy Pacheco and LPA Pete Espinoza conducted an unannounced case management inspection at the facility. LPAs met with Licensee, Maria Martinez, to discuss a Confirmation of Removal form that was mailed to the Licensee's mailing address from Department of Social Services, Caregiver Background Check Bureau, on June 5, 2019.

LPAs informed Licensee that although she returned the form to Community Care Licensing, it was not completed correctly. LPAs asked Licensee about the individual named on the Confirmation of Removal. Licensee stated she was considering hiring the individual to be her assistant, but she is no longer going to hire her. She said the individual has never lived at the home and she does not come to the home anymore. LPAs provided Licensee with a copy of a blank Confirmation of Removal form. Licensee completed and signed the form correctly and gave to LPAs.

Per California Code of Regulations Title 22, Division 12, no deficiencies cited today.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Kathy PachecoTELEPHONE: (559) 341-5116
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
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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