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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444411318
Report Date: 09/03/2019
Date Signed: 09/03/2019 12:24:45 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:DIAZ, VERONICAFACILITY NUMBER:
444411318
ADMINISTRATOR:DIAZ, VERONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 722-1815
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:14CENSUS: 14DATE:
09/03/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Veronica DiazTIME COMPLETED:
12:40 PM
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A case management was conducted by analyst Behbood to deliver an amended report dated 08/06/19. Present were licensee, her helper and 14 day care children. Purpose of visit explained. The amended report delivered.
No citation issued.


SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2019
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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