Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364814533
Report Date: 12/07/2016
Date Signed: 12/07/2016 11:16:44 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:
12/07/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Un SalazarTIME COMPLETED:
11:30 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 deliver the Inconclusive findings regarding a previous incident. The investigation of this incident is closed as of 12/07/16.

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: 12/07/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2016
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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