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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618010
Report Date: 07/26/2023
Date Signed: 07/26/2023 01:25:59 PM

Document Has Been Signed on 07/26/2023 01:25 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DIMOVA, VERAFACILITY NUMBER:
343618010
ADMINISTRATOR:DIMOVA, VERAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 225-0105
CITY:ELVERTASTATE: CAZIP CODE:
95626
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Vera DimovaTIME COMPLETED:
01:35 PM
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On July 26, 2023 at 12:50 PM, Licensing Program Analyst (LPA) Tanya Washington met with Licensee Vera Dimova for an unannounced case management inspection. Upon arrival Licensee informed LPA that she has not been providing any childcare since 2018. Licensee requested to be placed on inactive status until she is able to find clients.

LPA did not conduct an inspection of the facility. Licensee filled out form LIC9211 and requested inactive status from 07/26/2023 until 07/26/2024.

Licensee agrees to comply with the conditions of inactive status.

LPA will update the LIS system upon return to the office and send the inactive license to Licensee Dimova.

Licensee understands that if she wishes to come off the inactive status prior to 07/26/2024, she must call the Regional Office or LPA Washington.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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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