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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393608056
Report Date: 12/03/2019
Date Signed: 12/03/2019 03:47:53 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:ROSAS, MARIAFACILITY NUMBER:
393608056
ADMINISTRATOR:ROSAS, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 835-8315
CITY:TRACYSTATE: CAZIP CODE:
95377
CAPACITY:14CENSUS: 9DATE:
12/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Maria RosasTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Jeevun Birk-Miller and Licensing Program Manager (LPM) Jeanne Smith met with the Licensee, Maria Rosas to serve her an Order of Exclusion for adult #1. LPM and LPA also served adult #1 with an exclusion order which prohibits adult #1 from being present in the facility and prohibits adult #1 from having contact with day care children. Appeal rights were provided and explained to adult #1. An Addendum to Notification of Parent's Rights (Regarding Removal/Exclusion) was provided to the Licensee with instructions. The Licensee is to have all her clients/parents sign and return the Addendum to the Licensee where she will keep the original signed copy in the children's files. In addition, the Licensee shall provide a copy of the signed Addendum's to the Department no later than December 9, 2019. An exit interview was conducted.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019
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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