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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197402655
Report Date:
12/20/2022
Date Signed:
01/20/2023 08:45:07 AM
Document Has Been Signed on
01/20/2023 08:45 AM
- 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
,
300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO
,
CA
90245
FACILITY NAME:
UCLA EARLY CARE & EDUC. UNI. VILLAGE C.C.C.
FACILITY NUMBER:
197402655
ADMINISTRATOR:
NEGIN ZOMORODI
FACILITY TYPE:
850
ADDRESS:
3233 S SEPULVEDA BLVD
TELEPHONE:
(310) 915-5827
CITY:
LOS ANGELES
STATE:
CA
ZIP CODE:
90034
CAPACITY:
90
CENSUS:
DATE:
12/20/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
TIME COMPLETED:
10:30 AM
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SUPERVISOR'S NAME:
Mary Ruiz
TELEPHONE:
(424) 301-3061
LICENSING EVALUATOR NAME:
Lisa Clayton
TELEPHONE:
(424) 301-3206
LICENSING EVALUATOR SIGNATURE:
DATE:
12/20/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/20/2022
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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