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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423937
Report Date: 07/25/2024
Date Signed: 07/25/2024 11:12:31 AM

Document Has Been Signed on 07/25/2024 11:12 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: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/25/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mayra ZubizarretavelascoTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On July 25, 2024 at 9:00am Licensing Program Analyst (LPA) Indira Loza met with Licensee Mayra Zubizarretavelasco for a Case Management - Licensee Initiated visit for the purpose of inspecting an "Off Limit" area to convert to "On Limits". Present during today's visit were Licensee and her small dog. LPA conducted a walk through of the home for a health and safety check.

The area inspected to converted to "On Limit" was a portion of the backyard which was sectioned off for the children. The children area in the backyard is fully enclosed with baby gates and has a plenty of shade. The Licensee plans on taking the children to the backyard through the right side of the house. The gated portion of the backyard has been approved to be "On Limits".

The On Limit Areas are the living room, kitchen, first bedroom to the left of the hallway, and the bathroom to the left in the hallway, the walkway on the right side of the house, and the gated portion of the backyard (on the left side of the backyard).

The Off Limit Areas are the first bedroom on the right, the master bedroom, master bathroom, the patio space adjacent to the master bedroom, and the section of the backyard that is not enclosed with the baby gates, and the walkway on the left side of the house. The off limits areas are made inaccessible by gate, closed and/or locked doors and visual supervision.

The Licensee was provided with Technical Assistance regarding follow-up questions from the pre-licensing visit conducted on April 11, 2024.

There were no deficiencies cited during today's visit.

Exit interview conducted.


Report and Appeal Rights provided to Licensee Mayra ZubizarretaVelasco.
Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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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