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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376608782
Report Date: 11/23/2020
Date Signed: 11/23/2020 10:14:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:RIVAS, ROSA & FAUSTO FAMILY CHILD CAREFACILITY NUMBER:
376608782
ADMINISTRATOR:RIVAS, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 475-4686
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:14CENSUS: 4DATE:
11/23/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Rosa & Fausto Rivas TIME COMPLETED:
08:20 AM
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On November 23, 2020 at 08:00 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted a case management inspection regarding annual fees and Provider Information Notice (PIN) 20-24-CCP/ Safe Sleep. LPA advised Licensees of the meeting’s purpose. Due to the COVID 19 outbreak, this inspection was done as a tele visit via the FaceTime platform. Present in the daycare were zero (0) infants, two (2) toddlers, two (2) school aged children, and both Licensees.

Licensee Fausto Rivas and LPA discussed the facility’s annual fees. LPA electronically provided Licensee with Provider Information Notice (PIN) 20-10.

LPA electronically provided Licensees with PIN 20-24-CCP and a blank copy of form LIC 9227 Individual Infant Sleeping Plan. Licensees agreed to use the LIC 9227 form.

A Notice of Site Visit (LIC 9213) is to be posted for thirty (30) days. LPA electronically provided this document to the Licensees. An exit interview was conducted. A copy of this report and Licensee/Appeal Rights (LIC 9058) will be e-mailed to the Licensee. The Licensee was advised that acknowledgement of the receipt of the report is to be received within twenty-four hours.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
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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