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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629162
Report Date: 09/29/2021
Date Signed: 09/29/2021 05:30:46 PM

Document Has Been Signed on 09/29/2021 05:30 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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:MIRANDA, KEYLLY FAMILY CHILD CAREFACILITY NUMBER:
376629162
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
09/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Keylly MirandaTIME COMPLETED:
05:30 PM
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 On September 29th, at 3:45PM, LPA, Luigi Gargaro, conducted an unannounced case management visit to the facility. Visit was conducted so that analyst could ask licensee questions about her operational and supervision practices and confirm facility personnel and home residents. Analyst conducted interviews with licensee, family members who also assist in the day care and children in care. Analyst printed out a copy of visit report to have licensee sign and maintain a copy for her records.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Luigi Gargaro
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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