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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393619809
Report Date: 02/20/2025
Date Signed: 02/20/2025 09:52:40 AM

Document Has Been Signed on 02/20/2025 09:52 AM - 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:HERNANDEZ, ELVIA & ANTONIOFACILITY NUMBER:
393619809
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, ELVIA & ANTONIOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 426-6244
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
02/20/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Licensee Elvia HerandezTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 2/20/25, Licensing Program Analyst (LPA) Carla Polanco met with licensee Elvia Hernandez for the purpose of amending a 9099 report and 9099-D report that was originally created on 1/2/25. During today's visit there were 3 children being supervised by Licensee.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
Karyn GuerraTELEPHONE: (916) 216-7790
Carla Polanco RiveraTELEPHONE: (916) 212-0752
DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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