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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444410956
Report Date: 08/30/2019
Date Signed: 09/03/2019 01:13:27 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:PALMERIN, ESTELAFACILITY NUMBER:
444410956
ADMINISTRATOR:ESTELA PALMERINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 728-8094
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:14CENSUS: 10DATE:
08/30/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Estela PalmerinTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee, Estela Palmerin for an unannounced case management inspection. Purpose of today's inspection is to follow up on an Unusual Incident that the Licensee self reported to Community Care Licensing on Friday, August 2, 2019. LPA observed 10 children in care; 3 infants 6 preschoolers, Licensee's 6 year old daughter and Licensee's assistant/husband.

LPA advised Estela Palmerin that further investigation is required and a follow up inspection will be conducted at a later date.

No deficiencies issued during today's inspection.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2019
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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