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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500395
Report Date: 04/30/2021
Date Signed: 04/30/2021 03:36:34 PM

Document Has Been Signed on 04/30/2021 03:36 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:PINA, NIZARINDANDIFACILITY NUMBER:
394500395
ADMINISTRATOR:PINA, NIZARINDANDIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 833-5761
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
04/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Nizarindandi PinaTIME COMPLETED:
03:30 PM
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NOTE: Due to Covid-19 and DPH guidelines on physical distancing, a Tele-visit via FaceTime was conducted. On Friday, April 30, 2021, at 3:00 pm Licensing Program Analyst (LPA) Elvira Sierra conducted a Case Management inspection and met with Licensee,Nizarindandi Pina. Census included 5 children (2 infants, 3 preschool). The Licensee is requesting to change the guest bedroom (bedroom #1) to be accessible to the daycare children and part of the daycare areas.

At 03:00 pm, with the help of the Licensee, LPA inspected the guest bedroom. LPA approved the guest bedroom to be part of the daycare areas in today's inspection.

In the areas that were evaluated, no deficiencies were observed at the time of the inspection. Please note: When a physical inspections takes place, requests for alterations may be made. This report (LIC 809), and a Notice of Site Visit (LIC 9213) will be delivered to the Licensee electronically via email. Acknowledgement of delivery will constitute acknowledgement of the report in lieu of a signature
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2021
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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