Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364814533
Report Date: 10/26/2016
Date Signed: 10/26/2016 10:43:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SALAZAR FAMILY CHILD CAREFACILITY NUMBER:
364814533
ADMINISTRATOR:SALAZAR, UNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 373-6888
CITY:BARSTOWSTATE: CAZIP CODE:
92311
CAPACITY:14CENSUS: 4DATE:
10/26/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Un SalazarTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA), Joanne Domingo arrived at the facility to conduct a case management visit. Licensee, Un Salazar granted LPA Domingo access into the home. The purpose of this visit was to obtain copies of facility records. Due to Licensee's printer not working, LPA Domingo took cell phone photo's of the facility's records.

There were no citations issued during this visit.

A Notice of Site visit was posted and a copy of this report was provided to Licensee, Un Salazar on this date and time.
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Joanne DomingoTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2016
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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