<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620962
Report Date: 11/21/2023
Date Signed: 11/21/2023 02:49:04 PM

Document Has Been Signed on 11/21/2023 02:49 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ROBLES E. ROSAFACILITY NUMBER:
393620962
ADMINISTRATOR:ROBLES E. ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 740-1419
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
11/21/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Licensee Rosa RoblesTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/21/23, Licensing Program Analyst (LPA) Carla Polanco met with Licensee Rosa Robles to follow up on a Unusual Incident Report (UIR) called into Community Care Licensing on 9/1/23.

During today's inspection LPA conducted a tour of the facility. LPA observed and verified that the broken window had been replaced.

Facility evaluation report was reviewed and discussed with Rosa Robles. Exit interview was conducted. A Notice of Site Visit was provided and 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.


In the areas that were evaluated, no deficiencies were cited during today's inspection.

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1