Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503600291
Report Date: 01/16/2019
Date Signed: 01/16/2019 10:32:06 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:EMPIRE HEAD STARTFACILITY NUMBER:
503600291
ADMINISTRATOR:CENTENO, CONSUELOFACILITY TYPE:
850
ADDRESS:5201 FIRST STTELEPHONE:
(209) 527-9884
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:20CENSUS: 19DATE:
01/16/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Connie CentenoTIME COMPLETED:
10:45 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
LPA Claudia Henley conducted a case management visit. I was met by Connie Centeno, Site Supervisor. Tour of the facility conducted and census was taken.

The department had received a document (LIC 300B) "Confirmation of Removal" form from the Caregiver Background Check Bureau on December 21, 2018. The purpose of today's visit was to ensure that a staff member had been removed from the facility due to a criminal record exemption being denied by the department. Staff member was not present at the facility.

Upon staff interviews, the staff member had never been hired to work for the district and was awaiting a fingerprint clearance with the department.

No deficiencies were cited. Site Visit Notice posted.
SUPERVISOR'S NAME: Valarie ReedTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 341-5776
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2019
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