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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005458
Report Date: 08/28/2019
Date Signed: 08/28/2019 11:14:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BAKER, TEREIFACILITY NUMBER:
214005458
ADMINISTRATOR:BAKER, TEREIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 747-5582
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:14CENSUS: 4DATE:
08/28/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Licensee, Terei Baker TIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Luis J. Gomez met with licensee Terei Baker. Purpose of the visit was explained and is for a case management visit to deliver the amended the 809 and 809-D from previous inspection done on 08/21/2019. Present is the Licensee and helper caring for 4 children. ( 4 infant, 0 preK ). All adults in the home have criminal record clearance on file. Licensee is within capacity of the license. During today's visit, LPA Gomez observed licensee sign the amended 809 and 809-D annual report from the inspection on 8/21/2019. Copy of the amended report was provided to licensee.

>No deficiencies were issued today under Title 22 Division 12 of the Ca. Code of Regulations.

> This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2019
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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