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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313622857
Report Date: 01/22/2020
Date Signed: 01/22/2020 11:14:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:VAUGHAN, DOLLY & RODRIGUEZ, MARIAFACILITY NUMBER:
313622857
ADMINISTRATOR:VAUGHAN, DOLLY & RODRIGUEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 275-6230
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:14CENSUS: 6DATE:
01/22/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Dolly and Thomas Vaughan -TIME COMPLETED:
11:30 AM
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An unannounced case management inspection was conducted today by Licensing Program Analyst Owens and Soto.

The purpose of the case management inspection is to conducted additional interviews.

No deficiency issued at tine of inspection.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina OwensTELEPHONE: 916-263-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020
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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