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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202655
Report Date: 12/22/2020
Date Signed: 12/22/2020 04:17:06 PM

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. 350
SAN JOSE, CA 95131
FACILITY NAME:MARQUEZ LIVING I (RCFE)FACILITY NUMBER:
435202655
ADMINISTRATOR:MARQUEZ LORENZO, MARIAFACILITY TYPE:
740
ADDRESS:994 SOBRATO DRTELEPHONE:
(408) 533-2829
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:14CENSUS: 13DATE:
12/22/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria Marquez LorenzoTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced Case Management visit today and met with administrator Maria Marquez Lorenzo

The purpose of LPA's visit was to verify and confirm that the facility received the Immediate Exclusion Letter for employee, S1, and to verify that S1 is no longer present at the facility.

Based on interview with Maria and LPA's observation during today's visit, LPA has verified that S1 is not present, employed, or residing at the facility. Licensee has been advised to disassociate S1 from their roster. An updated LIC 500 was requested by LPA to be received by the end of the day today.

Verification of removal is complete. Exit interview conducted with Maria and 809 delivered for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2020
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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