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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
274450197
Report Date:
11/04/2021
Date Signed:
01/04/2024 10:28:32 AM
Document Has Been Signed on
01/04/2024 10:28 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
SAN JOSE CC RO
,
2580 N FIRST STREET, STE. 300
SAN JOSE
,
CA
95131
FACILITY NAME:
AYALA, OLGA
FACILITY NUMBER:
274450197
ADMINISTRATOR:
OLGA AYALA
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(831) 536-5077
CITY:
WATSONVILLE
STATE:
CA
ZIP CODE:
95076
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
4
DATE:
11/04/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:17 PM
MET WITH:
TIME COMPLETED:
03:18 PM
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LPA Berumen conducted a visit to the home to obtain signature on report dated 10/28/2021.
SUPERVISORS NAME
:
Mary Segura
LICENSING EVALUATOR NAME
:
Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/04/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/04/2021
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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