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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318374
Report Date: 05/13/2019
Date Signed: 05/13/2019 10:43:56 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:CORDOVA VILLA ELEMENTARY SCHOOLFACILITY NUMBER:
340318374
ADMINISTRATOR:CHAVEZ, AUNDRIAFACILITY TYPE:
850
ADDRESS:10460 REYMOUTH AVENUETELEPHONE:
(916) 366-6181
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:22CENSUS: 19DATE:
05/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Aundria Chavez PerezTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA), Jan Hoshida, and Licensing Program Manager (LPM), Bettina Engelman, met with Lead Teacher, Aundria Chavez Perez, for a case management visit on this date to discuss the unusual incident report (UIR) that was submitted on 4/11/2019. LPA observed 19 children with four staff present.

LPA conducted interviews and observed care and supervision of children in care.

No deficiencies were cited in today’s visit.

Exit interview was conducted, Appeal Rights were provide and the Notice of Site Visit was posted.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2019
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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