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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623025
Report Date: 11/05/2020
Date Signed: 11/05/2020 11:20:36 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:HERNANDEZ, ANNABELFACILITY NUMBER:
343623025
ADMINISTRATOR:HERNANDEZ, ANNABELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 759-0414
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:14CENSUS: 5DATE:
11/05/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Annabel HernandezTIME COMPLETED:
11:30 AM
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At 11:10 a.m. on Thursday, November 5th, 2020, Licensing Program Analyst (LPA) Karyn Guerra met with Licensee, Annabel Hernandez for an announced case management inspection. A tele-inspection was conducted due to COVID-19. All individuals subject to criminal background check have obtained clearance.

Licensee wishes to make off-limits living room 2 an on-limits area. Licensee guided LPA on a tour of the room. Living room 2 appeared to be free from hazards. Effective today, 11/5/2020, living room 2 is on-limits. Licensee understands that she must contact LPA to make any off-limit areas on-limits. Licensee acknowledges that off-limit areas will remain inaccessible by closed doors and/or supervision. Licensee will submit LIC999 Facility Sketch form with updated on-limits area.

This facility evaluation report was reviewed and discussed with Licensee. This report and a Notice of Site Visit will be provided electronically to the Licensee. Acknowledgement of receipt of report will be documented in lieu of signature. Notice of Site Visit shall remain posted at the facility for 30 days. In the areas that were evaluated, no deficiencies were observed at the time of the visit.

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 216-7796
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
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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