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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622149
Report Date: 02/22/2023
Date Signed: 02/22/2023 02:52:42 PM


Document Has Been Signed on 02/22/2023 02:52 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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:TYSON, ANGELAFACILITY NUMBER:
393622149
ADMINISTRATOR:TYSON, ANGELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 572-1011
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:14CENSUS: 4DATE:
02/22/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Licensee Angela TysonTIME COMPLETED:
03:10 PM
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On 2/22/23, Licensing program Analyst (LPA) Carla Polanco conducted an unannounced case
management visit and met with Licensee, Angela Tyson. LPA was granted entry by Licensee. Today's inspection was for the purpose of converting the off-limit backyard in the FCCH back to on-limit areas.

During today's visit there were 4 children present being supervised by Licensee.

During the inspection, LPA observed that the fence in the backyard was still in need of fixing, a number of the planks were still missing. Licensee stated that she thought only the entrance to the fence needed to be fixed. Licensee and LPA discussed the importance of the backyard fence being entirely fixed. Licensee stated that she understood and that she would have the planks to the fence fixed as soon as possible. The backyard will remain off-limit.

Exit interview conducted and report was reviewed with the licensee. 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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Carla Polanco RiveraTELEPHONE: (916) 212-0752
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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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