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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622373
Report Date: 10/25/2019
Date Signed: 10/25/2019 11:29:37 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:GODINEZ, JUANITAFACILITY NUMBER:
343622373
ADMINISTRATOR:GODINEZ, JUANITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 230-6190
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:14CENSUS: 4DATE:
10/25/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Licensee- Juanita GodinezTIME COMPLETED:
11:50 PM
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Licensing Program Analyst (LPA) Amy Silva conducted an unannounced case management inspection and met with Licensee, Juanita Godinez. The purpose of the inspection is in follow up to the incident that was reported to the department that occurred on October 4, 2019 when the Licensee was involved in a car accident and had children in the car. LPA Silva interviewed Licensee regarding the children in the car during the accident and Licensee stated the accident occurred when she was driving her own children to school in the morning and there were no day care children in the car at the time of the accident. Licensee stated her children were not hurt in the accident.

No deficiencies were observed or cited during the inspection. Notice of Site was provided and posted.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Amy SilvaTELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019
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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