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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393619802
Report Date: 06/19/2023
Date Signed: 06/19/2023 04:41:10 PM


Document Has Been Signed on 06/19/2023 04:41 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:LOPEZ, MARIAFACILITY NUMBER:
393619802
ADMINISTRATOR:LOPEZ, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 942-3843
CITY:STOCKTONSTATE: CAZIP CODE:
95203
CAPACITY:14CENSUS: 8DATE:
06/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria LopezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Corina Beckby met with Licensee, Maria Lopez, to follow up on the Unusual Incident Reports (UIR) submitted to Community Care Licensing on 6/16/23.

LPA toured the facility, observed the care and supervision of children, reviewed records, reviewed roster, and conducted interviews.

Facility evaluation report was reviewed and discussed with Licensee. Exit interview was conducted. A Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
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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