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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
444415239
Report Date:
11/03/2022
Date Signed:
11/05/2022 03:28:52 PM
Document Has Been Signed on
11/05/2022 03:28 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
,
2580 N FIRST STREET, STE. 300
SAN JOSE
,
CA
95131
FACILITY NAME:
CHAVEZ, CARMEN
FACILITY NUMBER:
444415239
ADMINISTRATOR:
CHAVEZ, CARMEN
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(831) 345-7762
CITY:
FREEDOM
STATE:
CA
ZIP CODE:
95019
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
8
DATE:
11/03/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:15 PM
MET WITH:
Carmen Chavez
TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo met with licensee Carmen Chavez for a Case Management inspection. LPA explained to licensee the nature of today’s visit is for obtaining the licensee signature on the inspection report dated 11/01/22. Inspection report dated 11/01/22 lost the licensee signature due to technical difficulties. Present were eight children included two infants and six preschool age. Present was Licensee's helper Ilda.
No deficiencies were cited today.
SUPERVISORS NAME
:
Mary Segura
LICENSING EVALUATOR NAME
:
Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/03/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/03/2022
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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