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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198014088
Report Date:
05/10/2019
Date Signed:
05/14/2019 09:22:00 AM
COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1000 CORPORATE CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
SHACK FAMILY CHILD CARE
FACILITY NUMBER:
198014088
ADMINISTRATOR:
SHACK, FELICIA
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(310) 639-3443
CITY:
CARSON
STATE:
CA
ZIP CODE:
90746
CAPACITY:
14
CENSUS:
0
DATE:
05/10/2019
TYPE OF VISIT:
Annual/Random
UNANNOUNCED
TIME BEGAN:
01:12 PM
MET WITH:
TIME COMPLETED:
01:20 PM
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SUPERVISOR'S NAME:
Brandi VanOosten
TELEPHONE:
(323) 981-3439
LICENSING EVALUATOR NAME:
Susann Sanchez
TELEPHONE:
(323) 981-3366
LICENSING EVALUATOR SIGNATURE:
DATE:
05/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/14/2019
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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