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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409137
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:16:02 PM


Document Has Been Signed on 01/09/2024 03:16 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:NOTRE DAME INFANT CENTERFACILITY NUMBER:
197409137
ADMINISTRATOR:ANGELICA RODRIGUEZFACILITY TYPE:
830
ADDRESS:21704 GOLDEN TRIANGLE RD.#120TELEPHONE:
(661) 255-0053
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY:30CENSUS: 21DATE:
01/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Angelica Rodriguez, DirectorTIME COMPLETED:
03:30 PM
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On Tuesday, January 9, 2024 Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced case management inspection and met with Director Angelica Rodriguez. During this visit, LPA Rivera reviewed the consent to transition to toddler program. LPA Rivera cleared the Type B citation.

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted, during which this report and the Appeal Rights were discussed with Director Angelica Rodriguez.


SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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