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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
312701015
Report Date:
07/13/2022
Date Signed:
07/13/2022 11:39:14 AM
Document Has Been Signed on
07/13/2022 11:39 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
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
MOTHER CONCHING LLC
FACILITY NUMBER:
312701015
ADMINISTRATOR:
GOMEZ, MARCO
FACILITY TYPE:
740
ADDRESS:
7253 LIVERPOOL LANE
TELEPHONE:
(916) 365-7994
CITY:
ROSEVILLE
STATE:
CA
ZIP CODE:
95747
CAPACITY:
6
CENSUS:
4
DATE:
07/13/2022
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
09:15 AM
MET WITH:
Marco Gomez
TIME COMPLETED:
11:45 AM
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Post Licensing visit is conducted in 07/13/22 inspection.
No deficiencies are cited.
See 809 for Annual visit for 07/13/22 for details.
Exit interview done and copy of the report left at facility.
SUPERVISORS NAME
:
Laura Munoz
LICENSING EVALUATOR NAME
:
Talwinder Bains
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/13/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/13/2022
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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