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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620128
Report Date: 06/17/2019
Date Signed: 06/17/2019 10:10:45 AM

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:NEGRON, ASHLEY MFACILITY NUMBER:
393620128
ADMINISTRATOR:NEGRON, ASHLEY MFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 221-0005
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:14CENSUS: 7DATE:
06/17/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ahsley NegronTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Mary Ponce met with licensee to conduct a Case Management- Other inspection for a confirmation of removal regarding an adult working in the home. During the inspection, LPA Ponce inspected all areas of the home both on limits and off limits. LPA did not observe the excluded adult present in the home and licensee stated the adult only comes over on the weekends. No deficiencies have been cited during the inspection. Notice of Site Visit has been provided and must remain posted for 30 days.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2019
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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