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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
585405125
Report Date:
08/01/2023
Date Signed:
08/01/2023 12:13:39 PM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
08/01/2023 12:13 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
CHICO CC RO
,
520 COHASSET RD., SUITE 170
CHICO
,
CA
95926
FACILITY NAME:
SIETSEMA, MARY FAMILY CHILD CARE HOME
FACILITY NUMBER:
585405125
ADMINISTRATOR:
SIETSEMA, MARY
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(530) 329-8658
CITY:
OLIVEHURST
STATE:
CA
ZIP CODE:
95961
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
0
DATE:
08/01/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:04 PM
MET WITH:
Attempted
TIME COMPLETED:
12:30 PM
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ON 8/1/23 LPAs E. Laird and S. Sims attempted to conduct a required one year inspection. Licensee was not home.
SUPERVISORS NAME
:
Megan Aviles
LICENSING EVALUATOR NAME
:
Sydney Sims
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/01/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2023
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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