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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115405057
Report Date: 10/21/2020
Date Signed: 03/30/2023 09:13:01 PM

Document Has Been Signed on 03/30/2023 09:13 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
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:FERNANDEZ, MARIA FAMILY CHILD CARE HOMEFACILITY NUMBER:
115405057
ADMINISTRATOR:FERNANDEZ, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 965-2691
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
10/21/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Maria FernandezTIME COMPLETED:
02:05 PM
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On 10/21/2020 at 1:20pm, Licensing Program Analyst (LPA) Laura Chavez conducted a case management inspection with Licensee Maria Fernandez in response to the Confirmation of Removal dated September 22, 2020. The inspection was conducted via tele-inspection due to the current State of Emergency caused by COVID-19. The signed Confirmation of Removal received on October 2, 2020 indicates Adult #1 was removed from the home on September 27, 2020. Based on evidence obtained during today’s tele-inspection, the LPA has verified the individual is not present, employed, or residing at the facility. The licensee was reminded that civil penalties and/or disciplinary action including suspension of her license could result if Adult #1 is found to be living in the home prior to the individual receiving a criminal record exemption.

All licensing reports are public information and must be made available upon request. At this time, there were no deficiencies noted of Title 22 Regulations. Verification of removal is complete.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2020
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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