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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406206384
Report Date: 12/19/2019
Date Signed: 12/19/2019 12:04:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CAPSLO - STEP BY STEP EARLY HEAD STARTFACILITY NUMBER:
406206384
ADMINISTRATOR:RUBY ALCANTARFACILITY TYPE:
830
ADDRESS:1055 MESA VIEW DRIVETELEPHONE:
(805) 474-3750
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:16CENSUS: 11DATE:
12/19/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Aurora HernandezTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPA) Martina Jimenez conducted an Case Management - Incident visit and met with the family services advocate-- Aurora Hernandez, to follow up on an incident that was self-reported to the department on December 16, 2019.

LPA obtained a copy of the children's roster, and interviewed the Licensee.




No citations were issued during this visit.

LPA observed Licensee post the Notice of Site visit



SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 387-5041
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019
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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