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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421709731
Report Date: 10/04/2022
Date Signed: 10/04/2022 10:47:37 AM

Document Has Been Signed on 10/04/2022 10:47 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CAC - GUADALUPE CENTERFACILITY NUMBER:
421709731
ADMINISTRATOR:ELVA QUINTANILLAFACILITY TYPE:
850
ADDRESS:130 TOGNAZZINI AVETELEPHONE:
(805) 343-5598
CITY:GUADALUPESTATE: CAZIP CODE:
93434
CAPACITY: 25TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
10/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Elva QuantillaTIME COMPLETED:
10:50 AM
NARRATIVE
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On 10/4/2022, at 10:37 AM Licensing Program Analyst (LPA) Martina Jimenez conducted an unannounced Case Management Inspection to deliver an amended LIC 809, and LIC 809C, reports, for inspection conducted on 9/26/2022.

LPA met with Elva Quantilla, Site Supervisor. LPA tour the inside and outside of the center. LPA observed eight (8) children playing in play in the outside play area, with two (2) staff.

LPA amended the report, altering potions of the narrative section, with the correct facility number. The report was reissued and signed.


During today's Visit, no deficiency was cited.

Exit interview was conducted with Elva Quantilla, Site Supervisor.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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