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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416045
Report Date: 03/07/2022
Date Signed: 03/07/2022 02:32:10 PM

Document Has Been Signed on 03/07/2022 02:32 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:RUIZ TORRES, EVELYNFACILITY NUMBER:
434416045
ADMINISTRATOR:EVELYN RUIZ TORRESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 716-7318
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
03/07/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Evelyn Ruiz TorresTIME COMPLETED:
02:40 PM
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On 03/07/2022 at 2:00 PM, Licensing Program Manager (LPM) Mary Segura and Licensing Program Analyst (LPA) Susy Cervantes met with applicant, Evelyn Ruiz Torres, for an office visit to test applicants comprehension of Title 22 regulations.

Applicant had previously submitted an orientation certificate that had to be retaken as part of their plan from the previous office visit on 02/10/2022. Applicant received 11/14 correct on the exam. Applicant will complete and submit a new LIC 279 application for a small FCCH, prior to a small FCCH license being granted.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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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