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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216956
Report Date: 09/02/2026
Date Signed: 09/02/2026 04:01:51 PM

Document Has Been Signed on 09/02/2026 04:01 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
426216956
ADMINISTRATOR/
DIRECTOR:		LOPEZ, LETICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 588-0716
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
09/02/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Leticia LopezTIME VISIT/
INSPECTION COMPLETED:
04:15 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 September 2, 2026 at 1:15 PM, Licensing Program Analysts (LPAs) Brian Fung and German Negrete conducted an unannounced Annual inspection. LPAs met with licensee Leticia Lopez and advised the purpose of the inspection. Licensee provided LPAs a tour of the home inside and out. There were 2 children in care at the time of the inspection and 2 adults in the home fingerprinted cleared and caring for children.

LPAs observed required Licensing required documents posted prominently at the living room. Fire and earthquake drills are not being documented every six months. Last drill was conducted on 9/20/2024. 1 technical violation was cited for missing the 6 month period of conducting and documenting fire and emergency disaster drill. Fire extinguisher 2A10BC mounted on the wall inside the school room was last serviced 6/11/2026. Fire and carbon monoxide detectors were tested at 1:30 PM and found to be in working condition.

Children in care have access to the living room and bathroom. Currently, the backyard is under construction to expand the shading roof and is not being used. Licensee did not provide proof of approval permit from the City of Lompoc and did not notify licensing in regards to making alterations to the facility. 1 technical violation was cited for making alterations to the building without notifying licensing. Licensee discussed with LPAs that for outdoor play, licensee and assistant go on walks. LPAs reminded licensee that children will need to be supervised at all times when going on walks outside the facility and at the local parks.

Continued on 809-C
Susana Martinez
Brian Fung
DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2026
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 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
Document Has Been Signed on 09/02/2026 04:01 PM - It Cannot Be Edited


Created By: Brian Fung On 09/02/2026 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 object which poses an immediate health, safety or personal rights risk to persons in care. A razor was found on the sink of the bathroom that is accessible to children.
POC Due Date: 09/02/2026
Plan of Correction
1
2
3
4
A meeting at the SBRO office will be scheduled at a later date. Licensee will remove the razor from the bathroom and move the razor to an area that is inaccessible to children.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Brian Fung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 09/02/2026 04:01 PM - It Cannot Be Edited


Created By: Brian Fung On 09/02/2026 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 fire drill record which poses/posed a potential health, safety or personal rights risk to persons in care. Fire drills are no conducted every 6 months and are not documented on the drill log. Last drill was documented on 9/20/24.
POC Due Date: 09/07/2026
Plan of Correction
1
2
3
4
Licensee will conduct a fire and/or emergency disaster drill with the chidlren and docuemnt on the drill log. A meeting at the SBRO office will be scheduled at a later date.
Type B
Section Cited
CCR
102417(g)(10)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in1 out of 1 object which poses/posed a potential health, safety or personal rights risk to persons in care. A baby walker was found in the facility where children were sleeping.
POC Due Date: 09/02/2026
Plan of Correction
1
2
3
4
Licensee will remove the baby walker from the facility. A meeting at the SBRO office will be scheduled at a later date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Brian Fung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 09/02/2026 04:01 PM - It Cannot Be Edited


Created By: Brian Fung On 09/02/2026 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review , the licensee did not comply with the section cited above in 1 out of 1 record which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee is missing mandated reporter training. Licensee is missing mandated reporter training.
POC Due Date: 09/07/2026
Plan of Correction
1
2
3
4
LIcensee will take the mandated reporter training and provide LPA a copy of the complete certificate. A meeting at the SBRO office will be scheduled at a later date.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. 1 out of 5 children file is missing immunization record. 4 out of 5 children files are missing LIC9224 form. 1 out of 5 children file is missing LIC995 parents rights.
POC Due Date: 09/07/2026
Plan of Correction
1
2
3
4
Licensee will contact families for the missing required licensing documents. A meeting at the SBRO office will be scheduled at a later date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Brian Fung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 09/02/2026 04:01 PM - It Cannot Be Edited


Created By: Brian Fung On 09/02/2026 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, record review, and observation, the licensee did not comply with the section cited above in 1 out of 1 record which poses/posed a potential health, safety or personal rights risk to persons in care. 1 out of 5 children files are missing the individual infant sleep plan.
POC Due Date: 09/07/2026
Plan of Correction
1
2
3
4
Licensee will contact the family for the missing LIC9227 form for infant in care. A meeting at the SBRO office will be scheduled at a later date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Brian Fung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
Page: 6 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216956
VISIT DATE: 09/02/2026
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
26
27
28
29
30
31
32
There are no fireplace located in the home. Kitchen cabinets were locked and knives are being kept in a locked cabinet to keep out of reach from children. Kitchen is also made inaccessible to the children with a extendable mesh gate. Children have access to toys that are age-appropriate inside and outside of the home. Back yard play area is enclosed and has plenty of play structures, activities, and toys for children to explore. There are no guns/ammunition located in the home. There are no bodies of water present at the time of inspection. During the tour, in the children's bathroom, there was a razor found on the sink. 1 type A deficiency was cited for having hazordous items made available to children. Because this is a repeat violation, a civil penalty was given for $250.00.

A roster of children in care was observed current and complete. LPA reviewed 5 out of 5 children files. 1 out of 5 children files are missing immunization records, 4 out of 5 children files are missing LIC9224 signed forms, and 1 out of 5 children files are missing LIC995 parents rights forms. 1 type B deficiency was cited for missing required licensing documents. Licensee CPR/first aid is valid through 3/23/2028. Licensee was reminded a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter certification AB1207 every two years at www.mandatedreporterca.com Licensee’s mandated reporter certification is expired. 1 type B deficiency was cited for expired mandated reporter training.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for and removing any recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Fung
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC809 (FAS) - (06/04)
Page: 10 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216956
VISIT DATE: 09/02/2026
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
26
27
28
29
30
31
32
Licensee discussed that a safe sleep log being documented for infants in care every 15 minutes was not being documented. A technical violation was cited for missing 15 minute infant sleep checks. Another technical violation was cited for having a blanket covering infant under 12 months of age sleeping in a crib. During the tour with the licensee, a baby walker was found in the living room play room where children were sleeping. 1 type B deficiency was cited for having a baby walking in the facility.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

There were 5 type B deficiencies, 1 type A deficiency, and 3 technical violations cited on today's inspection. Licensee was invited to the Santa Barbara Regional Office for a meeting to discuss the the current and previous deficiencies. A civil penalty for a repeat violation is assessed for $250.00.

LPAs Brian Fung and German Negrete informed licensee Leticia Lopez that this report dated 9/2/26 document 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.



Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Fung
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC809 (FAS) - (06/04)
Page: 11 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216956
VISIT DATE: 09/02/2026
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
26
27
28
29
30
31
32
Also, LPAs Brian Fung and German Negrete informed the licensee to provide a copy of this licensing report dated 9/2/26 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

During the exit interview, the Licensee Leticia Lopez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days on, or immediately adjacent to, the interior side of the main door. Appeal rights were given.

Exit interview conducted and report was reviewed with the licensee Leticia Lopez.

NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Fung
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC809 (FAS) - (06/04)
Page: 12 of 12