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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243909809
Report Date: 09/27/2021
Date Signed: 09/28/2021 09:45:22 AM

Document Has Been Signed on 09/28/2021 09:45 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:AYALA, MANUEL & DOMINICA FAMILY CHILD CAREFACILITY NUMBER:
243909809
ADMINISTRATOR:AYALA, MANUEL & DOMINICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 384-3643
CITY:MERCEDSTATE: CAZIP CODE:
95341
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
09/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Manuel Ayala TIME COMPLETED:
02:00 PM
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On 09/27/21, Licensing Program Analyst (LPA) Angelica Slaughter conducted an unannounced Case Management Inspection at the facility. The purpose of this inspection was to discuss concerns the department has regarding previous incidents that occurred in the facility.
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Angelica Slaughter
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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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