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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620128
Report Date: 06/15/2023
Date Signed: 06/15/2023 01:31:32 PM

Document Has Been Signed on 06/15/2023 01:31 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NEGRON, ASHLEY MFACILITY NUMBER:
393620128
ADMINISTRATOR:NEGRON, ASHLEY MFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 814-4222
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
06/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Ashley Negron TIME COMPLETED:
10:30 AM
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On June 15, 2023, Licensing Program Analyst (LPA) Stacey Williams met with Licensee, Ashley Negron to follow up on information Community Care Licensing received on May 30, 2023.

LPA toured the facility, observed the care and supervision of children, reviewed documents and conducted interviews.

Facility evaluation report was reviewed and discussed with Licensee, Ashley Negron. Exit interview was conducted. A Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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