Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618696
Report Date: 11/19/2019
Date Signed: 11/19/2019 02:00:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:RODRIGUEZ, TINAFACILITY NUMBER:
343618696
ADMINISTRATOR:RODRIGUEZ, TINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 271-6040
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:14CENSUS: 8DATE:
11/19/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Tina RodriguezTIME COMPLETED:
02:07 PM
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Licensing Program Analyst (LPA) Jeevun Birk-Miller conducted a Plan of Correction inspection and met with Licensee, Tina Rodriguez. During the inspection the Licensee's assistant and eight children were present. LPA reviewed ten children's files and observed all the required documents in each child's file.

There were no deficiencies during today's visit. A notice of site of visit was provided and an exit interview was conducted.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019
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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