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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426203355
Report Date: 08/13/2019
Date Signed: 08/13/2019 10:41:13 AM

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:CAC - J. C. WASHINGTON CENTERFACILITY NUMBER:
426203355
ADMINISTRATOR:SILVIA SEGOVIANOFACILITY TYPE:
850
ADDRESS:201 W. CHAPEL ST.TELEPHONE:
(805) 922-2243
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:20CENSUS: 0DATE:
08/13/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ralph YbarraTIME COMPLETED:
10:50 AM
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A case management inspection was conducted by LPA S. Mendoza-Ceja who met with Program Manager Ralph Ybarra regarding the alteration to the existing playground area. The Program Manager stated he is requesting the approval of the Department for the expansion of the playground area and renovating the yard by adding new bike path, artificial turf, and deck.


LPA advised prior to approval the following must be completed:

1. Submit pictures of the playground once the fence is completed.
2. Obtain the fire clearance.


The Notice of Site Visit was posted. No deficiencies were observed.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
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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