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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543910985
Report Date: 08/26/2021
Date Signed: 08/26/2021 03:59:16 PM

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:ANDERSON, DEBRA FAMILY CHILD CAREFACILITY NUMBER:
543910985
ADMINISTRATOR:ANDERSON, DEBRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 824-0326
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:14CENSUS: 0DATE:
08/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Debra AndersonTIME COMPLETED:
04:10 PM
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An unannounced Case Management inspection was conducted today by Licensing Program Analyst (LPA) Jessika Thompson. LPA met with Licensee Debra Anderson. No day-care children were present on this date.

LPA Thompson conducted an unannounced Annual Random inspection on 08/25/21, however, due to computer issues, LPA Thompson was unable to provide Licensee with a copy of the LIC809, LIC809-C, LIC809-D, Appeal Rights, Civil Penalty Assessment, and Notice Of Site Visit forms associated to the inspection. On this date, LPA obtained pertinent signatures from Licensee and provided Licensee with copies of the aforementioned documents.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, no deficiencies were cited during today's inspection.

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: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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