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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 574500405
Report Date: 11/10/2021
Date Signed: 11/10/2021 11:17:22 AM

Document Has Been Signed on 11/10/2021 11:17 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:DIAZ, ISRAEL & MARTINEZ, JHINESKAFACILITY NUMBER:
574500405
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
11/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Jhineska MartinezTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Chayntel Hunter met with Licensee Jhineska Martinez for the purpose of a case management inspection. The purpose of today's visit is to change Licensee's backyard from off limits to on limits. All individuals subject to criminal background review have obtained a criminal record clearance. Census at the time of inspection was two children. Licensee's operating hours are Monday through Friday from 8:00 AM. to 5:30 PM.

Toxic and hazardous items are inaccessible to children. As of today 11/10/2021 the backyard will be changed to an on limits areas, accessible to children in care. Licensee has requested to make the off limit areas: laundry room, garage, rooms 1 & 2, master bedroom and master bathroom.

This facility evaluation report was reviewed and discussed with Licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee's signature on this form acknowledges receipt of this form.

In the areas that were evaluated, no deficiencies were cited during today’s inspection.
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Chayntel Hunter
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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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