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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701008
Report Date: 07/28/2021
Date Signed: 07/29/2021 11:59:17 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PLACE CALLED HOMEFACILITY NUMBER:
392701008
ADMINISTRATOR:VARGAS, BRANDIFACILITY TYPE:
740
ADDRESS:25820 MAGNOLIA AVETELEPHONE:
(714) 948-0381
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:11CENSUS: DATE:
07/28/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Brandi VargasTIME COMPLETED:
09:46 AM
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This is the second report for Post Licensing Visit created in error by Licensing Program Analyst Ashley Boothe on today's date. Please review first Post Licensing Visit report created on 7/28/2021 for details of today's inspection.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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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