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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001369
Report Date: 06/09/2022
Date Signed: 06/09/2022 03:50:45 PM

Document Has Been Signed on 06/09/2022 03:50 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HERNANDEZ, ROSARIO INGRIDFACILITY NUMBER:
414001369
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
06/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Rosario Ingrid HernandezTIME COMPLETED:
02:20 PM
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On June 9, 2022 at 1:38 PM, Licensing Program Analyst, (LPA) Cowan arrived at the facility to conduct an unannounced 1-Year Required inspection. LPA spoke with licensee at the door. Licensee states that her mother has had Covid-19, but she is now well. Licensee states that she now has a cold and is very sick and doesn't have any children in care. LPA observed child in the home. LPA inquired about the child, and licensee states that her ex-husband is watching children. Licensee inquired about adding her ex-husband to her license as well as applying for a large license. LPA informed licensee that LPA would return later in the month for the annual inspection and licensee can apply for a large license when she is ready. LPA discussed the importance of allowing LPA to come in and inspect once licensee is well.

This report is emailed to licensee with the request for reply demonstrating receipt.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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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