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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008934
Report Date: 06/13/2019
Date Signed: 06/13/2019 09:51:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:PEARCE/ANG FAMILY CHILD CARE HOMEFACILITY NUMBER:
483008934
ADMINISTRATOR:PEARCE, M/W & ANG, C.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 592-3088
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:14CENSUS: 12DATE:
06/13/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Mary PearceTIME COMPLETED:
10:00 AM
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A Confirmation of Removal letter (COR) dated 06/07/2019 was received by this Department.

On 06/10/2019, LPA Martinez contacted the Licensee and advised of the Confirmation of Removal as well as emailed the documentation. On 6/13/19 LPA Martinez conducted a Confirmation of Removal Case Management inspection to the facility. Licensee, Mary Pearce, stated the individual listed on the COR is in the process of moving out and has not stayed in the home since 6/10/19. LPA identified adults at the facility and observed that the individual was not present at the time of the inspection.

Based on evidence obtained and today's inspection, this LPA has verified the individual is not employed or residing at the facility. Licensee understands the appeal process for the exemption denial.

LPA found no evidence of this individual's presence at this facility, therefore LPA has determined the individual has been removed. Verification of removal is complete.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Mikah MartinezTELEPHONE: (530) 895-4014
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
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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