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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625196
Report Date: 12/11/2024
Date Signed: 12/11/2024 02:57:34 PM

Document Has Been Signed on 12/11/2024 02:57 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:KOPPULA, VIJAYA LAKSHMIFACILITY NUMBER:
343625196
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
12/11/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Vijaya Lakshmi KoppulaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Erwina Pascual-Golamco met with Licensee, Vijaya Lakshmi Koppula, to conducted a Case Management inspection. Purpose of inspection was explained.

Licensee requested LPA to include the living room accessible to children. LPA conducted a health and safety inspection, and observed that as of today, 12/11/24, the living room is ready as area accessible to children. No deficiencies cited in today's inspection, exit interview was conducted, and Notice of Site visit was provided and shall be posted where visible to parents for 30 days

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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