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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423937
Report Date: 04/18/2024
Date Signed: 04/18/2024 09:26:09 AM

Document Has Been Signed on 04/18/2024 09:26 AM - 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:ZUBIZARRETAVELASCO, MAYRAFACILITY NUMBER:
013423937
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mayra ZubizarettaVelascoTIME VISIT/
INSPECTION COMPLETED:
09:40 AM
NARRATIVE
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On April 18, 2024 at 9am Licensing Program Analyst (LPA) Indira Loza met with Licensee Mayra ZubizarettaVelasco to deliver an amended report dated April 11, 2024. LPA toured the home for a Health and Safety check.

There were no deficiencies cited during today's visit.

Exit Interview conducted.
Report and Appeal Rights provided to Licensee Mayra ZubizarrettaVelasco.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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