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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343621402
Report Date: 07/17/2023
Date Signed: 07/17/2023 03:51:30 PM

Document Has Been Signed on 07/17/2023 03:51 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DURAN, AZUCENAFACILITY NUMBER:
343621402
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 5DATE:
07/17/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Azucena DuranTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Corina Beckby met with Licensee, Azucena Duran on 07/17/2023 for the purpose of an unannounced plan of correction inspection to clear Type B deficiencies which were issued on 06/12/2023 for missing forms in children's Records/files.

There were 5 children during today's inspection. LPA toured the facility and found no deficiency. LPA reviewed 7 children's files. Licensee acquired all necessary Licensing Forms in each child's file clearing this deficiency. Licensee obtained immunization records for all children enrolled, clearing this deficiency. Licensee obtained signed Affidavit of Liability Insurance forms for each enrolled child, clearing this deficiency. Licensee obtained the Mandated Reporter training Certificate which expires 6/28/25, updated roster and conducted fire drills.



Deficiency cited on 06/12/2023 is cleared effective today, 07/17/2023. Proof of correction letter was provided. A notice of site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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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