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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620128
Report Date: 03/13/2020
Date Signed: 03/13/2020 03:07:07 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:NEGRON, ASHLEY MFACILITY NUMBER:
393620128
ADMINISTRATOR:NEGRON, ASHLEY MFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 221-0005
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:14CENSUS: 10DATE:
03/13/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Ashley NegronTIME COMPLETED:
03:15 PM
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On March 13, 2020 Licensing Program Analyst (LPA) Stacey Williams conducted a case management inspection at the home of Licensee, Ashley Negron. LPA met with Licensee and observed (10) ten children supervised by Licensee and her Assistant.

LPA conducted an interview with Licensee concerning an incident report submitted to Community Care Licensing. The home was also toured during today's inspection.

Based on the information received, there is no longer further inquiry.

An exit interview was conducted, and the licensing report was reviewed with Licensee. A copy of this report and appeal rights were discussed and left with Licensee whose signature on this form confirm receipt of these documents. Notice of Site Visit was provided to post during today’s inspection.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2020
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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