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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430753754
Report Date: 05/02/2019
Date Signed: 05/02/2019 03:07:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:COVARRUBIAS, ROSAFACILITY NUMBER:
430753754
ADMINISTRATOR:COVARRUBIAS, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 778-2719
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:14CENSUS: 4DATE:
05/02/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Rosa CovarrubiasTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced case management-other. LPA met with Licensee Rosa Covarrubias and explained the reason for the inspection. The purpose of the inspection is to get signature for 809 pg. 1 dated from 05/02/2019 and provided a copy of the report, appeal rights, and the notice of site visit. LPA was unable to provided a copy due to a consistency check.

No deficiencies have been cited as a result of this inspection. An exit interview was conducted where this report was discussed.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019
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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