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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415451
Report Date: 04/07/2022
Date Signed: 04/07/2022 08:21:09 AM

Document Has Been Signed on 04/07/2022 08:21 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:SERVELLON FAMILY CHILD CAREFACILITY NUMBER:
197415451
ADMINISTRATOR:SERVELLON, ELVIA & ROBERTOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 208-9110
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Elvia ServellonTIME COMPLETED:
08:47 AM
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On 4/7/2022, LPA visited Servellon FCC. Elvia answered the door. She shared with the LPA that she fall and is unable to take care of children. She also shared she closed the facility since 08/2021. Now she got hurt again, she would like to put her facility from 4/7/22 to 6/30/22.
Exit interview.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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