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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008305
Report Date: 07/19/2023
Date Signed: 07/19/2023 10:18:55 AM


Document Has Been Signed on 07/19/2023 10:18 AM - 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:LOJAS-PAREJO, HILDA FCCHFACILITY NUMBER:
493008305
ADMINISTRATOR:LOJAS-PAREJO, HILDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 992-0655
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY:14CENSUS: 6DATE:
07/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Facility representative Laura ParejoTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Elpidia Hernandez Torres made an unannounced visit to the facility and met facility representative Laura Parejo. The purpose of the visit is to confirm that the licensee has complied with the Immediate Exclusion Order of an individual (A1)
who previously lived in the home. The Immediate Exclusion Order was served by Certified Mail on 6/22/23 to the Licensee and the individual. Based on evidence obtained during today’s visit, the LPA has verified the individual is not present, employed, or residing at the facility. LPA has advised the licensee to disassociate the individual from their roster and submit an updated LIC500. The Licensee understands the terms and conditions of the Order including the appeal rights. A copy of this report was provided to Facility Representative Laura Parejo.

Verification of removal is complete.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
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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