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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426212030
Report Date: 03/04/2021
Date Signed: 12/22/2023 09:44:25 AM


Document Has Been Signed on 12/22/2023 09:44 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/01/2023 12:00 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

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The purpose of this amendment is to update the administrator's name.

On March 4, 2021 at 1:12 PM, Licensing Program Analyst (LPA) Francisco Pedroza, LPA Laura Villanueva, and Investigator Tiffany Brunelli conducted an unannounced case management inspection. LPAs and Investigator met with facility Site Supervisor Alicia Jimenez and advised the purpose of the inspection. Site Supervisor provided LPA Villanueva a tour of the facility. There were six children in care at the time of the inspection.



On February 26, 2021, Community Care Licensing (CCL) was informed of an incident that occurred off site during a field trip with another local company on February 5, 2021. LPAs and Investigator conducted staff interviews and record reviews. Due to insufficient information available at this time, the incident requires further investigation.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2021
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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