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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274417690
Report Date: 07/19/2023
Date Signed: 07/19/2023 09:21:25 AM

Document Has Been Signed on 07/19/2023 09:21 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:VELAZQUEZ LOPEZ, MARIAFACILITY NUMBER:
274417690
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Velazquez LopezTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo met with Maria S Velazquez Lopez, applicant, in a Case Management inspection. The purpose of the inspection is instructing applicant on how to transfer the exemption for her spouse Gustavo Chavez. LPA provided applicant with form LIC9188. LPA obtained from applicant a copy of her rental agreement.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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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