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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543910259
Report Date: 01/16/2020
Date Signed: 01/17/2020 08:46:18 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:CAMPOS, LUPITA FAMILY CHILD CAREFACILITY NUMBER:
543910259
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
01/16/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Lupita CamposTIME COMPLETED:
01:20 PM
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On this date, an unannounced Case Management - Plan of Correction (POC) Inspection was conducted by Licensing Program Analyst (LPA) Jessika Thompson. LPA met with Licensee Lupita Campos to review the POCs associated to deficiencies cited on 12/18/19. LPA has verified the following:

· Licensee has completed and logged a fire & disaster drill
· Licensee maintains proof of immunization for herself within the family child care home

LPA cleared deficiencies on this date and provided licensee with a "Letter of Deficiency Citations Cleared." This letter must be filed in the facility for three years and upon request made accessible to the public for review.

No deficiency cited on this date.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jessika ThompsonTELEPHONE: 559-341-4622
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
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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