<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153911810
Report Date: 07/06/2023
Date Signed: 07/06/2023 10:52:21 AM

Document Has Been Signed on 07/06/2023 10:52 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
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:RODRIGUEZ, ELIM FAMILY CHILD CAREFACILITY NUMBER:
153911810
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
07/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Elim RodriguezTIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/19/2023, Licensing Program Analyst (LPA), Gloria Reyes conducted an unannounced Case Management visit and was met by Licensee, Elim Rodriguez. The purpose of today's visit was to clear the deficiencies cited on 06/19/2023.

LPA verified that Licensee completed the LIC 9040 (Child Roster), LIC 9227 (Individual Infant Sleep Plan) and the Sleep Log. All corrections have been cleared.

Per California Code of Regulations, Title 22, Division 12, Chapter 3, no deficiency cited.



Exit interview conducted with licensee. A copy of this report was provided and discussed. A Notice of Site Visit Form was posted to parent's board and must remain posted for 30 days.
SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Gloria Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1