<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354413617
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:09:36 PM

COMPREHENSIVE INSPECTION
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:LEZAMA, SUSANAFACILITY NUMBER:
354413617
ADMINISTRATOR:LEZAMA, SUSANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 801-0501
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:14CENSUS: 3DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Susana LezamaTIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Susana Lezama for a required one year visit. Present was licensee, licensee's husband, licensee's two daughter in laws and three grandchildren. All live in the home including licensee's three adult sons.

Licensee stated she has been closed due to the pandemic and is not sure when she will be re-opening. Licensee states due to all the family that lives in the home, she thought it was best to close for the safety of her family, LPA provided licensee with LIC9211 to place her license inactive. Licensee stated she only cares for her grandchildren when needed.

No deficiency was cited.

A Notice of Site was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1