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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
013423286
Report Date:
11/02/2022
Date Signed:
11/02/2022 02:57:31 PM
Document Has Been Signed on
11/02/2022 02:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET STE 1102
OAKLAND
,
CA
94612
FACILITY NAME:
DALLAS, CALETHA
FACILITY NUMBER:
013423286
ADMINISTRATOR:
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
CITY:
STATE:
ZIP CODE:
CAPACITY:
8
TOTAL ENROLLED CHILDREN:
8
CENSUS:
0
DATE:
11/02/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:54 PM
MET WITH:
TIME COMPLETED:
03:15 PM
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Licensing Program Analyst Sidney Cortez knocked on the door a few times and called the number on file (no one answered the phone or the door). LPA Cortez left a voice mail
SUPERVISORS NAME
:
Wynn Norona
LICENSING EVALUATOR NAME
:
Sidney Cortez
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/02/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/02/2022
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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