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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618620
Report Date: 04/13/2020
Date Signed: 04/15/2020 10:52:49 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:STEPANOVA, ANNAFACILITY NUMBER:
343618620
ADMINISTRATOR:STEPANOVA, ANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 583-3335
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:14CENSUS: 4DATE:
04/13/2020
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anna StepanovaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst Tanya Washington contacted Licensee Anna Stepanova regarding her request to add a room which was previously identified as off-limits. Due to COVID-19 pandemic, LPA is conducting the meeting via FaceTime with Licensee. During the FaceTime visit, LPA Washington requested to tour the facility. LPA observed four children being supervised by Licensee.

The bedroom that is being added is the first bedroom in the hallway across the bathroom located on the first floor. The room is equipped with children's toys and two small beds for children's use.

Effective today the off limit areas of the home include: entire second floor, garage and left side yard.

The licensee updated her facility sketch and will submit an updated copy to LPA. Effective today the additional room is approved for use.

In lieu of Licensee's signature, LPA Washington is e-mailing the report with a read receipt request.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2020
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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