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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800568
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:39:34 PM

Document Has Been Signed on 08/26/2022 12:39 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:C.A.L.L.-D.T.A.C.FACILITY NUMBER:
405800568
ADMINISTRATOR:REGINA CEASARFACILITY TYPE:
775
ADDRESS:11700 VIEJO CAMINOTELEPHONE:
(805) 466-0766
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 45CENSUS: 28DATE:
08/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Regina Cesar, AdministratorTIME COMPLETED:
12:55 PM
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On 8/26/22 at 10:50 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced Case Management visit to follow-up on an incident that was reported by the facility. LPA met with Regina Cesar, Administrator, and explained the purpose of the visit.

LPA interviewed the administrator, collected documentation: Client roster, staff schedule, and Executive Director, Staff #1, Staff #2 statement declarations, and requested the following: photos of Laguna Lake Park picnic area where clients and staff picnicked on 8/19/22. Further investigation is needed. LPA will return at a later date.

Exit interview conducted and a copy of report emailed to administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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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