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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623759
Report Date: 05/16/2022
Date Signed: 05/16/2022 02:47:15 PM


Document Has Been Signed on 05/16/2022 02:47 PM - It Cannot Be Edited

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:IBARRA, AMELITAFACILITY NUMBER:
343623759
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
05/16/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Amelita IbarraTIME COMPLETED:
02:30 PM
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LPA arrived to do a capacity increase, fire inspection clearance. Licensee stated the appointment was on another day and was not ready. LPA did not have the appointment scheduled for another day, but agreed to return the following week.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Michelle PascualTELEPHONE: (916) 704-7665
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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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