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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111771
Report Date: 09/28/2022
Date Signed: 09/28/2022 02:12:51 PM


Document Has Been Signed on 09/28/2022 02:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BUSTOS, MARIA FAMILY CHILD CARE HOMEFACILITY NUMBER:
480111771
ADMINISTRATOR:BUSTOS, MARIA SOCORROFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 645-9627
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:14CENSUS: 0DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria Bustos - LicenseeTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced visit for the purpose of conducting a Required-1 Year inspection. During today's visit, LPA did not observe any day care children in care and the Licensee (LS) requested for the facility license to be placed on Inactive Status, LS completed and submitted an LIC 9211 to request for the license to be placed on Inactive status starting from 09/28/22 through 09/21/23. Department records indicated that the facility fee is current until 09/21/23. LS understood that the facility may be placed on inactive status for up to 12 months as long as the facility fee are current, and the inactive status may only be extended through the facility's anniversary date. LS also understood she may request for the facility status be changed from inactive status to licensed status prior to the end date, however; the facility is subject to an inspection prior to being placed on licensed status. LPA provided LS with California Code of Regulation(s) 102358 and discussed exempt care with LS. LS stated she understood that she could provide care for the children of only one family in addition to the operator's own children, and LS appeared to have acknowledged the regulations. This report was reviewed and discussed with the Licensee.

There were no violation(s) of Title 22, Division 12, chapter 1 cited during the visit.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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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