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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415859
Report Date: 05/23/2019
Date Signed: 05/23/2019 09:15:16 AM

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:CHAVEZ-ROCHA, BIANCAFACILITY NUMBER:
274415859
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
05/23/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Bianca Chavez-RochaTIME COMPLETED:
09:26 AM
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A follow up visit was made to inspect the required corrections needed prior to licensure. Met Bianca, Applicant. The following were inspected:

The tiles in the hallway and the lower part of the wall is now fixed.
The bath tub now has a shower curtain.
All the hazardous material in the front yard moved so the front yard appear to be safe
Proof TB clearance for applicant brother was provided.
A revised LIC 279B that includes renters' children name.

A revised LIC 279 to be submitted to change her respond to question #6 on the application and add all the adult who live on the property which should includes her renters.

Pending receiving the revised LIC 279, facility is now approved for licensure.

SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019
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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