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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573607570
Report Date: 04/29/2024
Date Signed: 04/29/2024 02:25:17 PM

Document Has Been Signed on 04/29/2024 02:25 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LARA, GUADALUPEFACILITY NUMBER:
573607570
ADMINISTRATOR/
DIRECTOR:		LARA, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 574-0121
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
04/29/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Guadalupe LaraTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Jennie Tedlos and Licensing Program Manager (LPM) Karyn Guerra conducted an announced case management inspection at the facility. The purpose of the inspection is to verify the required removal of the individual not cleared to work at the facility. LPA has confirmed Joanna Reynoso Lara has been removed and is not working or residing at the facility. LPA Tedlos verified that all adults present in the facility have a criminal record clearance.

Based on evidence obtained during today's inspection, the LPA has verified that the individual is not present, or employed, or residing at the facility. LPA has advised the licensee to disassociate the individual from their roster. Licensee will send LPA the Confirmation of Removal Letter.

As a result of today’s inspection, No Title 22 deficiency cited. Report was reviewed with Licensee Guadalupe Lara. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Verification of removal is complete.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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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