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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400854
Report Date: 06/08/2023
Date Signed: 06/08/2023 12:46:47 PM


Document Has Been Signed on 06/08/2023 12:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:RENGIFO, EMPERATRIZ & ARTUROFACILITY NUMBER:
073400854
ADMINISTRATOR:RENGIFO, EMPERATRIZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 687-7340
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:14CENSUS: 0DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Emperatriz RengifoTIME COMPLETED:
12:55 PM
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On June 08, 2023 at approximately 12:00 PM License Program Analysts (LPAs) Lorraine Dacanay Breaux and Jaleesa Jackson arrived for an Unannounced Random Inspection. Licensee and fingerprint cleared husband was present. Licensee stated that she would like to go inactive due to her husband's health. Licensee stated that she has not watched children due to her husbands health since March, 2020.

LPAs informed licensee (and son via cell phone Arturo Rengifo translated Spanish due to the language barrier. ) in order to go inactive $210 fees are due, and provided the PIN (Annual $140 plus late fees $70) and to complete the LIC9211. Son stated he will have the fees paid by June 23, 2023 and will call me to inform LPA fees paid.

Unable to complete annual inspection, due to licensee stating she has not been caring for children since March 2020 and would like to go inactive status. No children were at the home.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-BreauxTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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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