<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
304313293
Report Date:
08/09/2019
Date Signed:
08/11/2019 07:16:33 PM
COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
750 THE CITY DRIVE, SUITE 250
ORANGE
,
CA
92868
FACILITY NAME:
ESCALANTE, GENESIS
FACILITY NUMBER:
304313293
ADMINISTRATOR:
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
CITY:
STATE:
ZIP CODE:
CAPACITY:
8
CENSUS:
0
DATE:
08/09/2019
TYPE OF VISIT:
Annual/Random
UNANNOUNCED
TIME BEGAN:
11:14 PM
MET WITH:
TIME COMPLETED:
11:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
SUPERVISOR'S NAME:
Rina Lopez
TELEPHONE:
(714) 703-2808
LICENSING EVALUATOR NAME:
Stacy Torrence
TELEPHONE:
(714) 300-3599
LICENSING EVALUATOR SIGNATURE:
DATE:
08/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/11/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1