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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198019396
Report Date:
09/22/2022
Date Signed:
09/22/2022 10:03:21 AM
Document Has Been Signed on
09/22/2022 10:03 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
,
1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
AZUSA USD/VALLEYDALE CSPP
FACILITY NUMBER:
198019396
ADMINISTRATOR:
LESLIE FORD
FACILITY TYPE:
850
ADDRESS:
700 S LARK ELLEN
TELEPHONE:
(626) 815-4700
CITY:
AZUSA
STATE:
CA
ZIP CODE:
91702
CAPACITY:
60
CENSUS:
18
DATE:
09/22/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Jessica Estrada, Resource Teacher
TIME COMPLETED:
10:15 AM
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LPA Vasquez conducted a case management to obtain signatures for amendment reports on 09/22/22.
SUPERVISOR'S NAME:
Claudia Guangorena
TELEPHONE:
(323) 981-3417
LICENSING EVALUATOR NAME:
Fabiola Vasquez
TELEPHONE:
(626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE:
09/22/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2022
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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