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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
173010406
Report Date:
06/23/2023
Date Signed:
06/23/2023 10:01:16 AM
Document Has Been Signed on
06/23/2023 10:01 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
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
GUZMAN DE MONTEJANO, MARISOL FCCH
FACILITY NUMBER:
173010406
ADMINISTRATOR:
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
CITY:
STATE:
ZIP CODE:
CAPACITY:
8
TOTAL ENROLLED CHILDREN:
8
CENSUS:
DATE:
06/23/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Marisol Guzman
TIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Ouye arrived unannounced to conduct a case management visit to determine if an adult (A1) without an approved exemption resides at the home.
Upon arrival the licensee and her two children were present. No other individual was present in the home. There are two vehicles at the home. Both vehicles are registered to the licensee.
LPA Ouye with LPA Hernandez Torres (on speaker phone) spoke with the licensee and her two children. The licensee has already been interviewed. LPA's interviewed the children in private.
LPA Ouye will report findings to LPM and follow up with licensee regarding A1.
No deficiencies cited during the visit.
SUPERVISORS NAME
:
Leslie Lepori
LICENSING EVALUATOR NAME
:
Glenn Ouye
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/23/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/23/2023
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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