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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009277
Report Date: 01/26/2024
Date Signed: 01/26/2024 11:30:27 AM


Document Has Been Signed on 01/26/2024 11:30 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:BERNAL LOPEZ, LILIANA FCCHFACILITY NUMBER:
493009277
ADMINISTRATOR:BERNAL LOPEZ, LILIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 364-4546
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:14CENSUS: 0DATE:
01/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Liliana Bernal LopezTIME COMPLETED:
10:44 AM
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A case management visit was made to the facility today by Licensing Program Analyst (LPA) Y.Yang to conduct a confirmation of facility closure visit. The facility's licensee, Liliana Bernal Lopez submitted a request to close her facility on 01/26/24. During today's case management visit, the LPA observed no children in care or any evidence of childcare being provided at this address. A tour of the home was provided to the LPA by the licensee. The LPA provided the licensee with a confirmation of facility closure receipt letter during this visit.

Confirmation of facility closure is complete.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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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