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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416794
Report Date: 11/03/2022
Date Signed: 11/03/2022 11:14:19 AM

Document Has Been Signed on 11/03/2022 11:14 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ROSADO, MAYBELLINEFACILITY NUMBER:
274416794
ADMINISTRATOR:MAYBELLINE, ROSADOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 512-3136
CITY:SALINASSTATE: CAZIP CODE:
93907
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
11/03/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Maybelline Rosado TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Elizabeth Larios conducted an announced pre-licensing visit with Licensee Maybelline. The adults that reside in the home are as follows: Applicant, spouse, and minor children.

LPA Larios toured the physical plant (indoor and outdoor areas) of the home during today's visit to see pending items from prior inspection. LPA observed the following: Fire place in the living room has been barricade, fencing to the left side of house for off limit area has been added. Licensee submitted the following documents: TB test for herself & assistant, Mandated Reporter Certificate for herself, proof of vaccinations Measles, Pertussis and seasonal flu for herself, letter from Zaida to be removed from old license, leasing agreement, and update facility sketch (LIC 999A) to reflect added fence to the left side of house.

The following documents need to be submitted:

1. Submit a LIC 508 for spouse.
2. Submit a copy of Mandated Reporter Certificate for assistant.
3. Submit a copy of Prevention Health & Safety with Nutrition & Lead Prevention Certificate
4. Submit a copy of flu for assistant.

An exit interview was conducted with Licensee and was informed that upon submission of requested documents and approval of Licensing Management, a license for a Large Family Child Care Home will be granted and issued to Licensee.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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