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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415518
Report Date: 08/27/2021
Date Signed: 08/27/2021 08:22:12 AM

Document Has Been Signed on 08/27/2021 08:22 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:FUENTES CANO, ANAFACILITY NUMBER:
434415518
ADMINISTRATOR:FUENTES CANO, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 981-7161
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
08/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Ana Fuentes-CanoTIME COMPLETED:
08:30 AM
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Licensing Program Analyst (LPA) Janette Cruz, conducted an unannounced follow-up case management inspection today to deliver an amended report on a Plan of Correction Visit dated 08/18/21.

An exit interview was conducted with Licensee, Ana Fuentes-Cano.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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