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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001369
Report Date: 07/08/2022
Date Signed: 07/08/2022 11:01:37 AM

Document Has Been Signed on 07/08/2022 11:01 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
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: 6DATE:
07/08/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Rosario HernandezTIME COMPLETED:
11:15 AM
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On 7/8/2022 at 9:20AM., Licensing Program Analyst (LPA) Luis J. Gomez met with Licensee, Rosario Ingrid Herandez. Purpose of the inspection was explained and was for a plan of correction inspection; established on 6/28/2022. Present was the licensee and staff supervising six children (3 infant age and 3 preschool age). LPA inspected facility for health and safety hazards.

During inspection, LPA reviewed facility records, interviews and performed observations.

At 10:00A.M., Based on record review, LPA confirmed required LIC9224, 'Acknowledge Receipt of Licensing Report' has not been signed by children's authorized representatives.

Per licensee, day-care child, C9, will not longer be returning.

Based on today's inspection, no deficiencies were observed in the areas evaluated according the Title 22 Division 12 Ca. Code of Regulations. Exit interview was discussed with Licensee, Rosario Ingrid Hernandez and signature of this form acknowledges receipt of these documents.

This report must be available in the facility for public review. Notice was provided and must remain posted for 30 days. Director was advised for additional questions to call CCL Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022
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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