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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
434416004
Report Date:
07/06/2021
Date Signed:
07/06/2021 12:55:37 PM
Document Has Been Signed on
07/06/2021 12:55 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
,
2580 N FIRST STREET, STE. 300
SAN JOSE
,
CA
95131
FACILITY NAME:
CASILLAS, MARIAN & SANDOVAL, JUAN
FACILITY NUMBER:
434416004
ADMINISTRATOR:
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
CITY:
STATE:
ZIP CODE:
CAPACITY:
8
TOTAL ENROLLED CHILDREN:
0
CENSUS:
1
DATE:
07/06/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:35 PM
MET WITH:
Marian Casillas
TIME COMPLETED:
01:00 PM
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LPA Janet Tse met with licensee Marian Casillas to deliver an amended pre-licensing report. LPA explained the nature of today's visit to Licensee. Present was one infant with Licensee. Licensee's two minor children were also in the home.
No deficiency was cited. Notice of site visit was issued and must be posted for 30 days.
SUPERVISORS NAME
:
Mary Segura
LICENSING EVALUATOR NAME
:
Janet Tse
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/06/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2021
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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