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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243902523
Report Date: 07/14/2021
Date Signed: 07/14/2021 01:51:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:ORTIZ, JESSICA FAMILY CHILD CAREFACILITY NUMBER:
243902523
ADMINISTRATOR:ORTIZ, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 710-9360
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY:14CENSUS: 4DATE:
07/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jessica OrtizTIME COMPLETED:
02:15 PM
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On 07/14/2021 Licensing Program Analyst (LPA) Robert Gutierrez, conducted an unannounced case management – other inspection and was met by Licensee, Jessica Ortiz. Also present was Staff #1 (S1). The purpose of today’s inspection was obtain signatures from a report dated 07/06/2021. Due to a computer malfunction LPA was unable to obtain signatures for the report. During todays inspection LPA obtained signatures.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Robert GutierrezTELEPHONE: 559-243-4588
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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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