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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274410167
Report Date: 01/27/2020
Date Signed: 01/27/2020 02:51:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ROCHA, MARTHAFACILITY NUMBER:
274410167
ADMINISTRATOR:MARTHA ROCHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 422-1074
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY:14CENSUS: 2DATE:
01/27/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Martha RochaTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) met with Martha Rocha, Licensee, in a case management inspection with the purpose of amending report dated 09/11/2019. Licensee was present at home taking care of two children included one school age and one preschool age. LPA delivered a copy of the amended report LIC809 dated 9/11/2019 and a copy of the form LIC421FC (Civil Penalty Assessment - Failure to Correct and Repeat Violations). LPA obtained a copy of the children's roster today.

No deficiencies cited today.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2020
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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