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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566215775
Report Date: 05/17/2024
Date Signed: 05/17/2024 04:27:07 PM

Document Has Been Signed on 05/17/2024 04:27 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CASEY-LOPEZ FCC AKA CAMPANITA DAYCAREFACILITY NUMBER:
566215775
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
05/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:53 PM
MET WITH:Dolores LopezTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On May 17, 2024 at 3:53 PM, Licensing Program Analyst (LPA) Laura Villanueva made an unannounced visit to conduct a Case Management-Other Inspection. LPA met with licensee, Dolores Lopez and explained the purpose of the inspection. LPA toured the interior and exterior of the home while waiting for Licensee. Assistant was caring for 2 children at the time of the inspection. Licensee arrived with 2 school aged children.

The Department received an advisement letter regarding R1. LPA reviewed letter with Licensee and gave Licensee LIC855 Declaration to document who the individual is on the advisement is. R1 is Licensee's son and he does not reside in the home. Licensee provided R1's address.

Licensee understands that failure to comply with this notice to Licensee/Facility may be grounds for disciplining, including suspension or revocation of child care license.

Exit interview conducted and report was reviewed with the licensee, Dolores Lopez. Visit was conducted in Spanish.
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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