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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409329
Report Date: 08/23/2019
Date Signed: 08/23/2019 04:32:41 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:MARTINEZ, ANAFACILITY NUMBER:
434409329
ADMINISTRATOR:ANA MARTINEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 926-1903
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:14CENSUS: 4DATE:
08/23/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Ana MartinezTIME COMPLETED:
04:45 PM
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LPA Janet Tse met with licensee Ana Martinez for a Case Management inspection to deliver an amended report for the inspection conducted on 08/01/2019. There was a typo error on the report. LPA explained the nature of today's visit to her.

LPA observed 4 children in the home with Licensee and her husband who is also her assistant in the home.

The amended report dated 08/01/2019 was delivered to Licensee, and signatures were obtained today.

No deficiency was cited. Notice of site visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
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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