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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500249
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:33:27 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:ESQUIVEL, MARIA OLIVIAFACILITY NUMBER:
394500249
ADMINISTRATOR:ESQUIVEL, MARIA OLIVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 712-9167
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:14CENSUS: 4DATE:
10/07/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Maria Olivia EsquivelTIME COMPLETED:
03:30 PM
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On October 7, 2021, Licensing Program Analyst (LPA) Stacey Williams arrived at the facility for the purpose of conducting a case management inspection to change an off-limit area of the home to on limits. LPA met with Licensee, Maria Olivia Esquivel. LPA observed (4) four children supervised by the Licensee. All adult individuals subject to criminal background review have obtained a criminal record clearance and are cleared through the department.

Licensee guided LPA on the tour of the home. LPA observed the current off-limit area that Licensee would like to have on limits. Licensee is requesting the master bedroom to be on limits. The bedroom has a closed-door bathroom that will remain locked. The master bedroom has a sliding glass door. Licensee reported the room will be used for napping. The remaining off limit areas will be: bedroom#1, garage, and side yard.


Licensee will install an additional locking mechanism/door alarm on the sliding door in the master bedroom. LPA requested an updated facility sketch for the inside facility. Once received, on limits area will be updated.

An exit interview was conducted. Notice of Site Visit was provided and shall remain posted for 30 days.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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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