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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623381
Report Date: 06/19/2020
Date Signed: 06/19/2020 02:48:49 PM

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:VELASQUEZ, AMYFACILITY NUMBER:
343623381
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: DATE:
06/19/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Amy VelasquezTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christopher Bello had a Case Management Tele-inspection via FaceTime with Amy Velasquez. Also present was licensee’s husband and minor children. The purpose of the Tele-inspection was making the backyard of the home accessible to the children in care. LPA inspected the area and approved the space for the children to use. The off-limits areas in the home is the entire upstairs, all bedrooms and garage. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. LPA sent a copy of the report and Notice of Site visit to be posted for 30 days via email. Amy sent an email back confirming that she received the report acting as her virtual signature.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2020
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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