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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312536
Report Date: 10/04/2021
Date Signed: 10/04/2021 03:21:49 PM

Document Has Been Signed on 10/04/2021 03:21 PM - 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:BARAJAS, ANGELICAFACILITY NUMBER:
304312536
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
10/04/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Angelica Barjas, LicenseeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) P Rivas conducted a case management visit initiated by Licensee.
Ms. Barajas had requested to add a bedroom to facility floor plan. Licensee did not request an increase in capacity.

Upon arrival LPA noted 5 children asleep. At about 2:55 pm two more children arrived. Licensee was providing care. The home is a single story three bedrooms, two bathroom home. LPA also viewed, living room, dining area, kitchen. During today's visit LPA conducted a walk through of licensed area and bedroom requested. There is now only one bathroom and one bedroom that are off limits. The first bedroom to the right is off limits, the second bathroom on the left is off limits. The second bedroom on the right is the bedroom which will be added. There are only toys, supplies, a television in bedroom no furniture. LPA viewed a working smoke detector in bedroom #2

Based on LPAs observation bedroom #2 meets regulations and will be added to the facility sketch.

An exit interview was conducted, appeal rights given. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was read and reviewed with the licensee.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2021
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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