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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701015
Report Date: 07/29/2021
Date Signed: 07/29/2021 12:26:01 PM

Document Has Been Signed on 07/29/2021 12:26 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MOTHER CONCHING LLCFACILITY NUMBER:
312701015
ADMINISTRATOR:GOMEZ, MARCOFACILITY TYPE:
740
ADDRESS:7253 LIVERPOOL LANETELEPHONE:
(916) 365-7994
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 3DATE:
07/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marco Gomez, AdministratorTIME COMPLETED:
12:40 PM
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While at the facility conducting a Pre-Licensing inspection, Licensing Program Analyst (LPA) Praveen Singh conducted a Component III Orientation with Applicant/Administrators Marco Gomez and John Paul Pamintuan

During the inspection, Applicant/Administrator was provided with information to operate the facility within Title 22 regulatory compliance, as well as how to avoid common problem areas. Component III does not cover ALL regulations, only those found to be most problematic. Regulations require Administrator to be knowledgeable of all regulations and amendments to law.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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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