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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393616281
Report Date: 11/03/2023
Date Signed: 11/04/2023 10:38:56 AM

Document Has Been Signed on 11/04/2023 10:38 AM - 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:MEDINA, EVANGELINAFACILITY NUMBER:
393616281
ADMINISTRATOR:MEDINA, EVANGELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 465-9028
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 5DATE:
11/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Evangelina MedinaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Corina Beckby met with Licensee, Evangelina Medina on 11/06/2023 for the purpose of an unannounced plan of correction inspection to clear all deficiencies, issued on 10/12/2023.

LPA observed Licensee and assistant caring for 5 preschool children including 3 infants during today's inspection. LPA toured the facility and found no deficiencies.



LPA observed 11 children's files. All files had updated immunization's, LIC 700 forms, LIC 627 forms, Affidavit Regarding Liability forms, and signed LIC 9224 forms. LPA observed updated roster.

Five deficiencies cited on 10/12/2023 are cleared effective today. Proof of correction letters were provided for the corrected deficiencies. LPA reviewed report with Licensee, Evangelina Medina. Appeal Rights were 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: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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