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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416493
Report Date: 07/14/2022
Date Signed: 07/14/2022 09:52:51 AM

Document Has Been Signed on 07/14/2022 09:52 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:CACERES AGELVIZ, RAMON & RODRIGUEZFACILITY NUMBER:
434416493
ADMINISTRATOR:RAMON CACERES AGELVIZ & MIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 233-1595
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Milly RodriguezTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Mel Matos met with Milly Rodriguez, co-Applicant, for an unannounced prelicensing inspection. An Application for a Large Family Child Care Home was received from Milly and her spouse, Ramon Caceres Agelviz, on August 10, 2021. The fire clearance approval from the San Jose Fire Department has been received.

LPA advised Milly that the following items need to be submitted prior to the scheduled prelicensing inspection on Thursday July 21, 2022:

1) Updated certificates for Mandated Reporter Training for Child Care Workers for both Applicants.
2) Copies of flu vaccination for 2021/2022 for both Applicants.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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