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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103910228
Report Date: 05/31/2022
Date Signed: 05/31/2022 10:24:12 AM

Document Has Been Signed on 05/31/2022 10:24 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:MARTINEZ, SILVIA FAMILY CHILD CAREFACILITY NUMBER:
103910228
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
05/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Silvia MartinezTIME COMPLETED:
10:30 AM
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On 05/31/22, Licensing Program Analyst (LPA) Angelica Slaughter arrived at facility to conduct an unannounced annual inspection. LPA met with licensee Silvia Martinez. Also present was licensee’s husband and daughter. Licensee requested to place her license on inactive status due to medical reasons. A Request for Inactive Child Care License Status (LIC 9211) was completed during this visit. Licensee will be on inactive status from 05/31/22 through 11/30/22. Licensee has been instructed to follow the conditions listed on the inactive form. Licensee understands that if she wishes to become active prior to 12/01/22, she is advised to contact Community Care Licensing immediately.
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Angelica Slaughter
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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